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Level 4, 190 Queen Street, Melbourne 3000 Telephone: 03 8628.5561 Fax: 03 9642.5185
Offices in: Melbourne, Brisbane, Darwin, Canberra, Perth, Sydney, Adelaide
______________________________________________________________

TRANSCRIPT OF PROCEEDINGS
TRANSCRIPT-IN-CONFIDENCE
___________________________________________________________

INSPECTOR-GENERAL AUSTRALIAN DEFENCE FORCE

INQUIRY INTO THE CRASH OF A MRH-90 TAIPAN
HELICOPTER IN WATERS NEAR LINDEMAN ISLAND
ON 28 JULY 2023
PUBLIC INQUIRY

THE HONOURABLE M McMURDO AC

AVM G HARLAND AM CSC DSM

COL J STREIT, with FLTLT A ROSE and MAJ L CHAPMAN,

Counsel Assisting

LCDR M GRACIE, representing CAPT D Lyon

SQNLDR J GILES, representing LT M Nugent
MAJ H PEROTTET, with LCDR M TYSON, representing
CPL A Naggs
SQNLDR C THOMPSON, representing WO2 J P Laycock
COL N GABBEDY, representing MAJGEN Jobson
SQNLDR M NICOLSON, representing D10
MR G O’MAHONEY, representing Airbus Australia Pacific Limited
MS K MUSGROVE, representing the Commonwealth

1000, FRIDAY, 9 AUGUST 2024

DAY 16

TRANSCRIPT VERIFICATION
I hereby certify that the following transcript was made from the sound recording of the
above stated case and is true and accurate
Signed ......................................... Date ............... (Chair)
Signed ......................................... Date ............... (Recorder)
Signed Epiq Australia Pty Ltd Date 18/08/24 (Transcription)

.MRH-90 Inquiry 09/08/24

© C’wlth of Australia
 EXHIBIT LIST
Date: 09/08/2024

Number Description Page No

EXHIBIT 44 - STATEMENT OF CAPT JACKSON ........................ 2140

EXHIBIT 45 - STATEMENT OF CAPT GOODRIDGE

DATED 30/07/24 ........................................................................... 2159

EXHIBIT 46 - STATEMENT OF D129 DATED 24/07/24 ............... 2183

EXHIBIT 47 - STATEMENT OF GPCAPT POUNCEY

DATED 14/06/24 ........................................................................... 2212

EXHIBIT 48 - STATEMENT OF AIRCDRE MEDVED,

INCLUDING ADDITIONAL MATERIAL TO ANNEXURE A ...... 2235

EXHIBIT 49 - DSR AVFM ................................................................ 2259

EXHIBIT 50 - SUMMARY OF CHANGE RELEASED BY

DASR 28/10/21 .............................................................................. 2259
 WITNESS LIST
Date: 09/08/2024

Name Of Witness Page No.

CAPT BENJAMIN JACKSON, Sworn ................................................ 2138

EXAMINATION-IN-CHIEF BY FLTLT ROSE ................................. 2138
WITNESS WITHDREW ...................................................................... 2158

CAPT MATTHEW GOODRIDGE, Affirmed ...................................... 2158

EXAMINATION-IN-CHIEF BY FLTLT ROSE ................................. 2158
WITNESS WITHDREW ...................................................................... 2180

D129, Affirmed ..................................................................................... 2181

EXAMINATION-IN-CHIEF BY COL STREIT .................................. 2181
WITNESS WITHDREW ...................................................................... 2210

GPCAPT CHRISTOPHER POUNCEY, Affirmed............................... 2210

EXAMINATION-IN-CHIEF BY COL STREIT .................................. 2210
HEARING ADJOURNED .................................................................... 2216
HEARING RESUMED ......................................................................... 2217
CROSS-EXAMINATION BY LCDR GRACIE .................................. 2230
CROSS-EXAMINATION BY SQNLDR NICOLSON ........................ 2232
WITNESS WITHDREW ...................................................................... 2232

AIRCDRE JOSEPH JOHN MEDVED, Affirmed ................................ 2233

EXAMINATION-IN-CHIEF BY COL STREIT .................................. 2233
HEARING ADJOURNED .................................................................... 2272
HEARING RESUMED ......................................................................... 2272
CROSS-EXAMINATION BY MR O’MAHONEY ............................. 2274
CROSS-EXAMINATION BY LCDR GRACIE .................................. 2287
CROSS-EXAMINATION BY LCDR TYSON .................................... 2290
WITNESS WITHDREW ...................................................................... 2292
 MS McMURDO: Yes, FLTLT Rose.

FLTLT ROSE: Good morning, Ms McMurdo. The first witness I will be

calling is via video link, and I call CAPT Benjamin Jackson.
5 CAPT Jackson, can you see and hear me?

CAPT JACKSON: Yes, I can.

FLTLT ROSE: And I can see and hear you. Could you please state your
10 rank, your full name, and unit?

CAPT JACKSON: CAPT Benjamin Jackson. I’m currently posted to

B Company, 122, 3rd Aviation Regiment, (Indistinct), United States of
America.
15
FLTLT ROSE: Which town are you currently located in, or city?

CAPT JACKSON: The State of Alabama, in the City of Fort Novosel.

20 FLTLT ROSE: And what date is it there?

CAPT JACKSON: It’s currently 8 August.

FLTLT ROSE: And what time is it?

25
CAPT JACKSON: It is 1900.

FLTLT ROSE: Before we commence, I’m just going to ask the Court
Officer to take either an oath or to swear you in – either oath or affirmation.
30

<CAPT BENJAMIN JACKSON, Sworn

35 <EXAMINATION-IN-CHIEF BY FLTLT ROSE

FLTLT ROSE: I take it, CAPT Jackson, that all the responses that you
provided to me initially were the truth?
40
CAPT JACKSON: Yes, they are.

FLTLT ROSE: Can you confirm whether there is anyone in the room with
you now?
45

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 CAPT JACKSON: No, there is not.

FLTLT ROSE: And I think we didn’t quite establish what time it is where
you are?
5
CAPT JACKSON: It is 1900 on the evening of 8 August.

FLTLT ROSE: Thank you. Can you confirm you received the following
documents from the Inquiry: a section 23 Notice requiring your appearance
10 to give evidence?

CAPT JACKSON: I did.

FLTLT ROSE: An extract of the Inquiry’s Directions?

15
CAPT JACKSON: I did.

FLTLT ROSE: A copy of my appointment as an Assistant IGADF?

20 CAPT JACKSON: I did.

FLTLT ROSE: A Frequently Asked Questions Guide for Witnesses in

IGADF Inquiries?

25 CAPT JACKSON: I did.

FLTLT ROSE: And a Privacy Notice?

CAPT JACKSON: I did.

30
FLTLT ROSE: Did you prepare a statement for these proceedings?

CAPT JACKSON: I did.

35 FLTLT ROSE: Do you have a copy of that statement in front of you?

CAPT JACKSON: I do.

FLTLT ROSE: Could you confirm that that statement is dated 24 July
40 2024?

CAPT JACKSON: It is.

FLTLT ROSE: Is it five pages?

45

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 CAPT JACKSON: It is.

FLTLT ROSE: Is that your digital signature on page 5?

5 CAPT JACKSON: It is.

FLTLT ROSE: Do you wish to make any amendments to this statement?

CAPT JACKSON: I do not.

10
FLTLT ROSE: I tender the statement. I appreciate the witness hasn’t seen
the version that I would think we should use as the exhibit copy, but if it’s
appropriate, I tender this copy.

15 MS McMURDO: Yes. Is that Exhibit 44?

FLTLT ROSE: Forty-four.

MS McMURDO: Exhibit 44, thank you.

20

#EXHIBIT 44 - STATEMENT OF CAPT JACKSON

25 FLTLT ROSE: CAPT Jackson, can I please ask you to be mindful of your
security obligations. This hearing is being run at the “Official” level. If
you are asked any questions that you think the responses to which would
lead into a classification of “Official: Sensitive”, or higher, then please do
let us know. And if we need to take that evidence, we can do so in a private
30 hearing.

CAPT JACKSON: Understand.

FLTLT ROSE: You’ve also been provided with a pseudonym list prior to
35 appearing today. I may direct you at times to look at that pseudonym list.

CAPT JACKSON: I’ve got it.

FLTLT ROSE: I’ll start with your background and qualifications. You
40 joined the Army in 2014 and started your flying training in 2016; is that
correct?

CAPT JACKSON: That is correct.

45 FLTLT ROSE: You are qualified on a number of different aircraft,

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 including the CH-47F Chinook helicopter?

CAPT JACKSON: That is correct.

5 FLTLT ROSE: In 2019, you posted to C Squadron in 5 Aviation Regiment

in Townsville?

CAPT JACKSON: That is correct.

10 FLTLT ROSE: You performed various roles there, including Troop Pilot,
Troop 2IC, Aviation Safety Officer, Aviation Non-Technical Skills
Facilitator, and Squadron Training Officer?

CAPT JACKSON: Correct.

15
FLTLT ROSE: You’re currently posted, as you noted before, to the
US Army Aviation Centre of Excellence in Fort Novosel, Alabama?

CAPT JACKSON: That is correct.

20
FLTLT ROSE: Is that as a Chinook Instructor Pilot?

CAPT JACKSON: It is.

25 FLTLT ROSE: At paragraph 4 of your statement you state that prior to

this, you completed your Instructor Pilots’ Course in the US?

CAPT JACKSON: Yes.

30 FLTLT ROSE: Is that correct.

CAPT JACKSON: That is correct.

FLTLT ROSE: Was that also at Fort Novosel?

35
CAPT JACKSON: It was.

FLTLT ROSE: So when did you post to the US?

40 CAPT JACKSON: So I posted to the US in January of this year. So

15 January 2024 was my post-in date to the USA.

FLTLT ROSE: When will you post back to Australia?

45 CAPT JACKSON: 15 January 2025.

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 FLTLT ROSE: Which unit will you post back into?

CAPT JACKSON: I will post to the School of Army Aviation in

5 Townsville, the CH-47 Wing.

FLTLT ROSE: In paragraphs 5 to 7 of your statement you outline that you

are a Category A pilot.

10 CAPT JACKSON: Correct.

FLTLT ROSE: And that you are a six-year Captain.

CAPT JACKSON: Correct.

15
FLTLT ROSE: And an Aircraft Captain on the Chinook.

CAPT JACKSON: That is correct.

20 FLTLT ROSE: We can add to that also, now, a QFI on the Chinook, I take
it?

CAPT JACKSON: Well, I am not yet qualified as a QFI. So the way it

works for our CH-47, we undertake Instructor Pilot Course here at
25 Fort Novosel. We do our, what we call YOI, or year of instruction, on
United States Flight School Students, and then when I go back home to the
School of Army Aviation, I will conduct an Australian Instructor
Standardisation. Then from there, I will be categorised as an Australian
QFI.
30
FLTLT ROSE: Understood. At paragraph 12 of your statement, you set
out that you actually met WO2 Phil Laycock at Fort Novosel in Alabama
when he was on a course there in June or July 2023.

35 CAPT JACKSON: I did.

FLTLT ROSE: Do you remember what course he was on?

CAPT JACKSON: He was on the UH-60M AQC.

40
FLTLT ROSE: Is that a Black Hawk?

CAPT JACKSON: A Black Hawk course, yes.

45 FLTLT ROSE: Was it in relation to Aircrewman Instructor Training?

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 CAPT JACKSON: I can’t recall if it was Aircrewman Instructor Training
or if it was just a qualification course on the airframe.

5 FLTLT ROSE: I take it, though, you never flew with him on that airframe?

CAPT JACKSON: I did not.

FLTLT ROSE: Did you know CPL Alex Naggs?

10
CAPT JACKSON: I did not.

FLTLT ROSE: Did you know LT Max Nugent?

15 CAPT JACKSON: No, I did not.

FLTLT ROSE: I’ll ask you some questions now about a course you
undertook in 2022, the Regimental Officers’ Intermediate Couse. At
paragraph 15 of your statement, you set out that in 2022 – this is when you
20 were at C Squadron in Townsville – you attended the Regimental Officers’
Intermediate Course at Gallipoli Barracks and at Oakey.

CAPT JACKSON: I did.

25 FLTLT ROSE: Gallipoli Barracks is in Brisbane?

CAPT JACKSON: Correct.

FLTLT ROSE: Oakey is near Toowoomba in Queensland?

30
CAPT JACKSON: Yes, it is. Yes.

FLTLT ROSE: So the course was split between those two locations?

35 CAPT JACKSON: It was. I think we spent the first – it may have been; I
can’t recall – it may have been the first week or two at Gallipoli Barracks
in Brisbane, and then we went up to Oakey where the School of Army
Aviation is to complete the second-half of the course.

40 FLTLT ROSE: At paragraph 16 of your statement, you set out the other
persons or trainees that were on the course and they were all Captains, as I
understand?

CAPT JACKSON: Correct.

45

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 FLTLT ROSE: Can you turn to your pseudonym list and I will just ask
you to confirm certain persons that were on the course, some of whom have
pseudonyms, and some don’t. There was CAPT Matthew Goodridge?

5 CAPT JACKSON: Correct.

FLTLT ROSE: He’s a Chinook pilot from C Squadron as well?

CAPT JACKSON: Correct.

10
FLTLT ROSE: There’s CAPT Campbell Rogan?

CAPT JACKSON: Correct.

15 FLTLT ROSE: He’s also a Chinook pilot from C Squadron?

CAPT JACKSON: That is correct.

FLTLT ROSE: Now, if you could look to that pseudonym list, a person
20 with the pseudonym of D129, was he on the course?

CAPT JACKSON: Correct, he was.

FLTLT ROSE: Is that an MRH pilot from 6 Aviation Regiment?

25
CAPT JACKSON: Yes.

FLTLT ROSE: A person with the pseudonym of D15?

30 CAPT JACKSON: Yes.

FLTLT ROSE: Another MRH pilot from 6 Aviation Regiment?

CAPT JACKSON: Yes.

35
FLTLT ROSE: D55?

CAPT JACKSON: Yes.

40 FLTLT ROSE: Another MRH pilot from A Squadron in 5 Aviation

Regiment?

CAPT JACKSON: Correct. At the time, he was A Squadron.

45 FLTLT ROSE: Currently now in 6 Aviation Regiment?

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 CAPT JACKSON: Correct.

FLTLT ROSE: Then CAPT Danniel Lyon?

5
CAPT JACKSON: Correct.

FLTLT ROSE: He was an MRH pilot in 6 Aviation Regiment?

10 CAPT JACKSON: Correct.

FLTLT ROSE: Did you know CAPT Lyon prior to attending this course?

CAPT JACKSON: I did not personally know CAPT Lyon. I knew of him
15 from his time that he had spent over in New Zealand, but I didn’t personally
know him before the course.

FLTLT ROSE: So I take it you had never flown with him in a packet?

20 CAPT JACKSON: No, I had not, or not that I can recall.

FLTLT ROSE: At paragraph 17 you refer to a conversation you had with

DOPAW at the Gallipoli Barracks Officers’ Mess on the evening of
Wednesday, 10 August 2022.
25
CAPT JACKSON: Correct.

FLTLT ROSE: Can you confirm what “DOPAW” stands for?

30 CAPT JACKSON: The Director of Operational Airworthiness.

FLTLT ROSE: And who was DOPAW then?

CAPT JACKSON: COL Gilfillan.

35
FLTLT ROSE: You said you were in the mess. So was this a formal part
of the course you were on or an informal part of it, after hours?

CAPT JACKSON: So we just spent that day with COL Gilfillan

40 presenting some – did some professional military education and did some
presentations on case studies of some things. So after that had finished, we
went to the mess for an informal chat with him.

FLTLT ROSE: Were there any other course coordinators or presenters

45 from that course with you during this discussion in the mess?

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 CAPT JACKSON: No, there was not.

FLTLT ROSE: Was it the full cohort of trainees that I just read out that
5 were with you during the conversation at the mess?

CAPT JACKSON: It was the full cohort, yes.

FLTLT ROSE: You said that it was a frank and honest conversation that
10 you had with COL Gilfillan?

CAPT JACKSON: It was, yes.

FLTLT ROSE: What topics were you speaking about?

15
CAPT JACKSON: The topics at the time that we were discussing –
because we did see a lot of senior officials from Aviation throughout that
week while we were at Gallipoli Barracks, and the points that we brought
up were flying gloves not being acquired fast enough, because at the time
20 our flying gloves were an issue. Our flying boots, we’ve had a few issues
with them. That just didn’t seem to get fixed. And additional duties and
not enough time flying for Troop Pilots or senior Troop Pilots were the topic
of conversation.

25 FLTLT ROSE: At paragraph 18 you said that CAPT Lyon raised concerns
about the high tempo of his role in 6 Aviation Regiment.

CAPT JACKSON: Correct.

30 FLTLT ROSE: Do you recall what role he had at that time?

CAPT JACKSON: I don’t recall exactly what role it was. I think it was a
– it may have been a Troop 2IC or a Troop Commander; I’m unsure.

35 FLTLT ROSE: But you said that CAPT Lyon said that this had an effect
on him professionally and personally.

CAPT JACKSON: Correct, yes.

40 FLTLT ROSE: What kind of effect was that having on him professionally
and personally?

CAPT JACKSON: Dan was a very passionate and motivated aviator, and
his philosophy was if he didn’t do the job or if he just left the job open, it
45 would mean someone else would have to do it for him. So he was very

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 adamant in finishing off his work, tying up loose ends before going home.
So he would spend a lot of time at work.

FLTLT ROSE: When you say “complete his tasks”, are you referring to
5 the non-flying tasks that he had in his secondary role?

CAPT JACKSON: I am, yes.

FLTLT ROSE: You said that he raised concerns about night flying
10 recency and proficiency.

CAPT JACKSON: Yes, he did.

FLTLT ROSE: Can you recall what he said to COL Gilfillan about those
15 issues?

CAPT JACKSON: It was a while ago now, so I can’t recall exactly what
he said. It was to the effect of that they just don’t have enough time flying
at night for the complex tasks that they are to fly. Just not enough practice,
20 essentially, flying at night.

FLTLT ROSE: Was it the case that he said there wasn’t enough flying
hours available, or that he couldn’t find enough flying hours available
because of his secondary duty?
25
CAPT JACKSON: I’m unsure.

FLTLT ROSE: You said that he said that if the extra administrative
workloads weren’t reduced so they could spend more time flying, that
30 something catastrophic would happen.

CAPT JACKSON: Yes.

FLTLT ROSE: What do you think he meant by that?

35
CAPT JACKSON: I think he – it was pretty heated. I think he was a little
bit sick of saying the same thing over and over again to people, and he
would wear his heart on his sleeve. I sort of think he meant if nothing was
done – they were being vocal about it, that if nothing was done, I mean
40 something catastrophic – an aircraft crash – would happen.

FLTLT ROSE: Was this the only time that CAPT Lyon raised these
concerns during that course?

45 CAPT JACKSON: No, I think – it was a while ago now, but we would all

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 chat as a group, would have dinner together, would have coffees together,
would spend most of the days together, so we did discuss, from what I can
recall, the issues that all of the Regiments were facing, that we were facing.

5 FLTLT ROSE: So when you’re saying you discussed it, do you mean as a
cohort of trainees you discussed it amongst yourselves?

CAPT JACKSON: Yes, between ourselves.

10 FLTLT ROSE: Were there other sessions during the course where you
were also invited to provide frank and honest feedback to leadership and
Aviation Command?

CAPT JACKSON: Yes. The only other senior leaders that we met with
15 to discuss things with was the current – or at the time Brigade Commander,
the Brigade S3 and, on the pseudonym list, D9.

FLTLT ROSE: What role did D9 have?

20 CAPT JACKSON: He was the Brigade Major at the time.

FLTLT ROSE: Who was the Brigade Commander?

CAPT JACKSON: BRIG Thompson.

25
FLTLT ROSE: Is that Dean Thompson?

CAPT JACKSON: Dean Thompson, yes.

30 FLTLT ROSE: Was it SO3 or S3 that you referred to?

CAPT JACKSON: The S3 for Brigade, LTCOL Pidgeon.

FLTLT ROSE: So those were the only other three senior leaders that you
35 spoke to on the course?

CAPT JACKSON: At Gallipoli. And then when we got to Swartz

Barracks up in Oakey, COL Lynch – and I’m unsure if he was the
Commandant of AAvnTC or if he was the CO of SAA at the time.
40
FLTLT ROSE: Did CAPT Lyon raise his concerns about the high tempo
of work in 6 Avn, the impost of his secondary duties, and his concerns about
flying recency and proficiency at night with BRIG Thompson, D9 or
LTCOL Pidgeon?
45

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 CAPT JACKSON: I can’t recall.

FLTLT ROSE: But you do recall him saying those things to

LTCOL Gilfillan?
5
CAPT JACKSON: Yes, I do.

FLTLT ROSE: Did you share his concerns, as a Chinook pilot? That’s
CAPT Lyon’s concerns.
10
CAPT JACKSON: I did, yes.

FLTLT ROSE: What specifically? Is there workload concerns that you

shared, or is it about the secondary duties specifically and the lack of night
15 flying recency?

CAPT JACKSON: Yes. So I think the three of those things work

hand-in-hand with each other. As you can see from my statement, if I bring
you over to paragraph 9, under “Qualified Airframes”, the CH-47 split day
20 hours into night hours to NVD. I would say the most riskiest type of flying
that we do is at night, especially in low illumination or in formations. And
as you can see there, we fly significantly more during the day than we do
by night.

25 FLTLT ROSE: To be clear for those who don’t have the statement, your
total hours on the Chinook are 1120.6 flying hours.

CAPT JACKSON: Correct.

30 FLTLT ROSE: And that’s made up of 775.9 hours by day.

CAPT JACKSON: Correct.

FLTLT ROSE: 334.7 hours by night, with 229 hours on NVD.

35
CAPT JACKSON: Correct.

FLTLT ROSE: And 170 hours in formation, approximately.

40 CAPT JACKSON: Correct.

FLTLT ROSE: So your evidence is that there is significant more flying

hours during the day, and less at night, and even less on NVDs, and in
formation, even though that is the most complex flying that you can do.
45

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 CAPT JACKSON: Correct.

FLTLT ROSE: Is it your evidence that - - -

5 CAPT JACKSON: I will - - -

FLTLT ROSE: No, I won’t assume. You go ahead.

CAPT JACKSON: Right. I will add further to that. As we discussed, I’m

10 a Category A pilot. I’ve been in the Squadron for about six or seven years
now. My total hours on a Chinook relative to everyone else in the Squadron
are quite high, but when you compare it to, say, a civilian aircraft pilot or a
civilian helicopter pilot, they are quite low.

15 FLTLT ROSE: Is there a reason for that?

CAPT JACKSON: As Army pilots, we just don’t fly as much as other

organisations outside Defence.

20 FLTLT ROSE: When you say “Army pilots”, are you also comparing that
to the other Services: Air Force and Navy?

CAPT JACKSON: I haven’t actually spent any time in Air Force or Navy
to comment on their flying rates.
25
FLTLT ROSE: Can I take it from your evidence that you wish that you
could be flying more?

CAPT JACKSON: Absolutely.

30
FLTLT ROSE: And, if possible, doing more night flying to improve your
skills on NVDs and flying at night.

CAPT JACKSON: Correct.

35
FLTLT ROSE: And that one of the reasons you aren’t flying as many
hours as you would like to is because of your secondary duties that you’ve
been assigned.

40 CAPT JACKSON: Correct.

MS McMURDO: You said the risk is flying at night, low illumination and
in formation. Did night-vision devices add another layer of risk?

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 CAPT JACKSON: Yes, ma’am, they do. However, using night-vision
devices at night significantly reduces the risk, as opposed to if you didn’t
have them at all.

5 MS McMURDO: But, of course, that’s right because the whole purpose of

them, of course, is to make your vision better at night. But on the other
hand, is there another layer of complexity that comes with using them?

CAPT JACKSON: There is. Absolutely there is, ma’am. And it’s a
10 perishable skill. So if it’s not practised quite regularly, the skill operating
on night-vision devices degrades quite rapidly.

MS McMURDO: Thank you.

15 FLTLT ROSE: What system do you use as a Chinook pilot for

night-vision devices?

CAPT JACKSON: ANVIS.

20 FLTLT ROSE: So you’ve never used TopOwl?

CAPT JACKSON: I’ve never used TopOwl, no.

FLTLT ROSE: You gave evidence that you shared CAPT Lyon’s
25 concerns that he raised with COL Gilfillan. Did you also voice similar
concerns to COL Gilfillan during that session in the mess?

CAPT JACKSON: I was in agreeance with CAPT Lyon. I don’t think I

raised the same concern myself.
30
FLTLT ROSE: Did other trainees or participants on the course raise their
concerns as well as CAPT Lyon?

CAPT JACKSON: So that was what – so his concern was what stuck out
35 to me the most. I can’t recall the other conversations that we had in there,
but we were all – the cohort was all in agreeance with his concerns.

MS McMURDO: Did you communicate your agreement to

COL Gilfillan?
40
CAPT JACKSON: Yes, ma’am.

MS McMURDO: Thank you.

45 FLTLT ROSE: How did COL Gilfillan respond?

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 CAPT JACKSON: He took it on board. I can’t recall anything else that
was said after that. Much like most meetings with senior leadership, they
just take your concerns on board and you just trust that they’ll deal with it
5 in good faith.

FLTLT ROSE: You used the word “heated” before, when describing the
conversation. Why was it heated, or who was getting heated?

10 CAPT JACKSON: So I think – so CAPT Lyon and D15 are quite – I think
are quite good friends, and they spend a lot of time together at 6 Aviation
Regiment, and they share a couple of common hobbies. So I think, between
the two of them, they were – at a point, I guess, they were frustrated, and I
guess that can show itself in those kind of discussions.
15
FLTLT ROSE: Do you recall what role or secondary duties D15 had at
that time in 6 Aviation Regiment?

CAPT JACKSON: I’m unsure.

20
FLTLT ROSE: Was this a once-off occasion for you to share your
concerns about issues like this with senior leadership in Aviation
Command, or have you been given other opportunities to be frank and
honest about issues that are concerning pilots at other times in your career?
25
CAPT JACKSON: We have been given opportunities – not that I can
recall off the top of my head – but there are quite often opportunities for us
to bring up concerns that feel like are out of our reach to fix at the local
level. We had – towards the end of last year, KPMG conducted a town hall
30 with all the Aviation Regiments. And that was conducted online and they
– I can’t recall the exact questions, but it was a lengthy process and they
gathered comments and feedback from pilots at all the different Regiments.
But I’m unsure the progress or the status of that report from KPMG.

35 FLTLT ROSE: Do you understand what the purpose of that town hall was,
or why KPMG were involved?

CAPT JACKSON: No, I do not.

40 FLTLT ROSE: Did you, at that time, share any views during that town hall
similar to issues that you may have raised to COL Gilfillan?

CAPT JACKSON: Yes, I would have.

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 FLTLT ROSE: Was that orally, or was it through a survey, or a chat
function?

CAPT JACKSON: It was through a chat function. It was an online live

5 chat across all of the Regiments at once.

FLTLT ROSE: Have you ever been briefed on any follow-up from
KPMG’s project?

10 CAPT JACKSON: No, I have not.

FLTLT ROSE: If I understand your evidence, it was a town hall and all
pilots across Aviation Regiment – or was it wider than that, aircrew
generally – invited to attend that town hall?
15
CAPT JACKSON: I’m unsure if the aircrewman had their own
opportunity, but I think it was just pilots from across the three Regiments.

FLTLT ROSE: Do you remember when that was? You said late last year,
20 was it?

CAPT JACKSON: I can’t recall if it was late last year or late the year
before; I’ve been in and out of the Squadron for the past couple of years.

25 FLTLT ROSE: Were the topics generally you were being asked about
workload, tempo, secondary duties? Was that the gist of it?

CAPT JACKSON: Yes, that was the theme.

30 MS McMURDO: Were you aware of any outcomes from that feedback?

CAPT JACKSON: No, ma’am, I was not.

MS McMURDO: What about when you had given previous feedback?

35 Did you ever notice any outcomes, any results, coming from that feedback?
For example, you mentioned the complaints about flying gloves, and the
flying boots being inadequate.

CAPT JACKSON: No, not personally. It was an issue raised by pretty

40 much all of the aircrew. We went through a period where our gloves
wouldn’t work on iPads or touchscreens, and the process to get new gloves
introduced into the system so we could use our iPads with the gloves was
quite lengthy. And the gloves that were introduced weren’t usable from an
aircrew perspective, just because of the fit. And it just went back and forth

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 for a number of years, to the point where people would go out and source
their own flying gloves.

FLTLT ROSE: We’ve also heard evidence that some people cut the
5 fingers out of their flying gloves.

CAPT JACKSON: That is correct. Yes, and it was approved to cut the
fingers – three fingers off the flying gloves. I’m not sure if it was early
2023 or late 2022 when the SFI came out to approve that, but we were –
10 people were doing that before then, just out of frustration.

AVM HARLAND: You’re currently in the United States. What do they

do to solve or work around these problems?

15 CAPT JACKSON: Sir, I haven’t actually spent any time at an operational

unit in the United States. And the Flight School here, as you could
appreciate, is quite down the line, and there’s not many issues that there are
workarounds for. So it kind of happens, yes, in accordance with all the
documents. I’m unaware of any issues that they’re trying to rectify at the
20 moment. Or I’m not privy to that.

AVM HARLAND: Do you have workable gloves that work on iPads and
the like while you’re flying over there?

25 CAPT JACKSON: Sir, yes, I do. I was issued two pair of gloves from the
clothing store here.

AVM HARLAND: Thank you.

30 FLTLT ROSE: What’s the issue with the boots, the flying boots?

CAPT JACKSON: So we had some boots, commonly referred to as

Terrors, five or six years ago now, and they were phased out and replaced
with a black-coloured variant of that boot, and they were very heavy and
35 very, very hot, as you can imagine, in the summer in Townsville, to wear.
We had them for a number of years with lots of complaints about wearing
them, to the point where people would horde their old boots and only wear
those boots for flying, just to kind of extend the Service life of them.

40 We have been issued new boots now that I find are quite good, but it did
take quite a while to - - -

FLTLT ROSE: Having heavy boots, apart from it being uncomfortable in

terms of heat, did it also affect your ability to hands and feet fly effectively?
45

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 CAPT JACKSON: No, I don’t think it affected that.

FLTLT ROSE: Just turning back to that KPMG town hall, was it just for
pilots or were there also senior leaders from Aviation Command that were
5 part of that KPMG project?

CAPT JACKSON: I can’t recall whoever it was on that.

FLTLT ROSE: Was it your understanding that whatever KPMG were

10 working on, they were going to feed those results back to senior leadership
and Aviation Command?

CAPT JACKSON: That was my understanding, yes.

15 FLTLT ROSE: Are you also aware of snapshot surveys?

CAPT JACKSON: I am, yes.

FLTLT ROSE: Have you participated in snapshot surveys?

20
CAPT JACKSON: I have, yes.

FLTLT ROSE: Have you received briefings of those results of those

snapshot surveys from your Commanders?
25
CAPT JACKSON: I’ve received a briefing every year from my
Commander that I’ve done a snapshot survey.

FLTLT ROSE: Does fatigue feature in the results of those snapshot

30 surveys?

CAPT JACKSON: It does, yes.

FLTLT ROSE: In what way?

35
CAPT JACKSON: Fatigue is usually the highest – or the worst reported
on, on the snapshot surveys.

FLTLT ROSE: I take it you’ve received some briefings – is it annually?

40
CAPT JACKSON: Annually, yes. Towards the start of the year is when
they’re released.

FLTLT ROSE: So you’ve received a briefing over, say, five or six years
45 that you’ve been in the Squadron.

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 CAPT JACKSON: I have, yes.

FLTLT ROSE: Can you recall what the trajectory of concerns are about
5 fatigue over that time? Are the complaints getting worse, or better, or
stabilised?

CAPT JACKSON: The complaints are fairly stabilised, and it’s more to
do with around – I’m talking specifically to C Squadron now. I haven’t
10 spent any time at 6 Aviation Regiment, 1 Aviation Regiment, or
A Squadron, when it was there in 5 Avn. But it’s normally around the
operational tempo of our Squadron. So we’re out for the December,
January, February period, for the hottest weather season, and Defence aid
to the civil community.
15
We come back, we work up our flight training recency. We get back into
our formation night flying/mission flying profiles, and then we’ll go into
our mid-year exercises. So our TALISMAN SABREs, HAMELs, that kind
of thing. And then towards the end of the year, we hope for high-density
20 altitude training over in Papua New Guinea – or this year, for instance, the
Indo-Pacific Excursion, IPE, towards the end of the year. So the operational
tempo is quite high, and I think that’s what contributes a lot to fatigue.

FLTLT ROSE: Are you aware of any tool that Aviation Command has
25 introduced following the incident on 28 July 2023 to enable aircrew to
assess their own fatigue levels at the start of crew duty, or prior to a sortie?

CAPT JACKSON: Yes. So I have seen the DFSB Fatigue Risk

Awareness Tool that’s been released. I haven’t personally used that tool.
30
FLTLT ROSE: Would you know when it was released to your Squadron?

CAPT JACKSON: I do not.

35 FLTLT ROSE: But was it after the incident on 28 July last year?

CAPT JACKSON: Yes, it would’ve been because I hadn’t used that tool
prior to that.

40 FLTLT ROSE: You mentioned TALISMAN SABRE just then. Were you
in the US on 28 July 2023?

CAPT JACKSON: I was, yes.

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 FLTLT ROSE: So you didn’t deploy on Exercise TALISMAN SABRE
2023?

CAPT JACKSON: I did not.

5
FLTLT ROSE: Paragraph 23 and 24 of your statement, your responses –
if you can turn to that – say, “As per paragraph 22”.

CAPT JACKSON: Yes.

10
FLTLT ROSE: Was that a response to some questions that you were asked
to answer as part of the section 23 Notice you were sent by the Inquiry?

CAPT JACKSON: Yes, it was.

15
FLTLT ROSE: And those questions were about your role, if any, that you
had on Exercise TALISMAN SABRE 2023.

CAPT JACKSON: Yes, that was the question.

20
FLTLT ROSE: And you replied as you did because you were not on
Exercise TALISMAN SABRE 2023.

CAPT JACKSON: Correct, I was not on TALISMAN SABRE 2023.

25
FLTLT ROSE: Those are my questions.

AVM HARLAND: Just a question for you regarding the ongoing snapshot
surveys and their routine reporting of fatigue as one of the most important
30 issues, in the time that you’ve spent at the Squadron – six to seven years –
have you seen any evidence of Command intervention to try and manage
fatigue?

CAPT JACKSON: Sir, not at the – at the local level, yes. So up to and
35 including CO of 5 Aviation Regiment, yes. I am unaware of anything
outside of that to help try and manage fatigue.

AVM HARLAND: Okay, great. Thank you.

40 MS McMURDO: Are there any applications to cross-examine? No? No

applications to cross-examine.

Thank you very much, CAPT Jackson, for coming forward. The Inquiry
greatly appreciates your assistance.
45

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 CAPT JACKSON: Thank you, ma’am.

<WITNESS WITHDREW
5

MS McMURDO: Yes, we can end the video link now and call the next
witness.

10 FLTLT ROSE: I call CAPT Matthew Goodridge.

<CAPT MATTHEW GOODRIDGE, Affirmed

15
<EXAMINATION-IN-CHIEF BY FLTLT ROSE

MS McMURDO: Just help yourself to water if you’d like some.

20
CAPT GOODRIDGE: Will do, thank you.

MS McMURDO: Yes, FLTLT Rose.

25 FLTLT ROSE: Can you please state your rank, your full name, and your
unit?

CAPT GOODRIDGE: CAPT Matthew Goodridge, and I’m at the

C Squadron, 5th Aviation Regiment.
30
FLTLT ROSE: Can you confirm you were sent the following documents
by the Inquiry: a section 23 Notice requiring your appearance to give
evidence today?

35 CAPT GOODRIDGE: I was.

FLTLT ROSE: An extract of the Inquiry’s Directions?

CAPT GOODRIDGE: I was.

40
FLTLT ROSE: A copy of my appointment as an Assistant IGADF?

CAPT GOODRIDGE: I was.

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 FLTLT ROSE: The Frequently Asked Questions Guide for Witnesses in
IGADF Inquiries?

CAPT GOODRIDGE: I was.

5
FLTLT ROSE: And a Privacy Notice?

CAPT GOODRIDGE: I was.

10 FLTLT ROSE: Did you prepare a statement for these proceedings?

CAPT GOODRIDGE: I did.

FLTLT ROSE: I hand you this document. Can you please confirm that
15 that’s the statement you prepared?

CAPT GOODRIDGE: Correct.

FLTLT ROSE: Is it dated 30 July 2024?

20
CAPT GOODRIDGE: It is.

FLTLT ROSE: Is it five pages?

25 CAPT GOODRIDGE: It is.

FLTLT ROSE: Is that your electronic signature on page 5?

CAPT GOODRIDGE: It is.

30
FLTLT ROSE: Do you wish to make any amendments to the statement?

CAPT GOODRIDGE: No, ma’am.

35 FLTLT ROSE: I tender the statement.

MS McMURDO: It will be Exhibit 45.

40 #EXHIBIT 45 - STATEMENT OF CAPT GOODRIDGE

DATED 30/07/24

FLTLT ROSE: Can I please ask you to be mindful of your security

45 obligations during your evidence today, and to let us know if I, or anyone

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 else, asks you a question that goes above the classification of “Official”?

CAPT GOODRIDGE: Yes.

5 FLTLT ROSE: And if we do need to, we can move into a private hearing
to hear those matters.

CAPT GOODRIDGE: Okay.

10 FLTLT ROSE: You have also been provided a pseudonym list. That’s that
A3 document before you. I will refer you to it at certain points, but you can
also look to it if you’re concerned you’re about to mention someone’s name
that you think may have a pseudonym.

15 CAPT GOODRIDGE: Okay.

FLTLT ROSE: I’ll start with your background and qualifications. Let’s
just start in paragraph 3 of your statement. You joined the Army in 2012.

20 CAPT GOODRIDGE: Correct.

FLTLT ROSE: You started your flying training in 2016.

CAPT GOODRIDGE: Correct.

25
FLTLT ROSE: In 2018 you posted to C Squadron at 5 Aviation Regiment
as a CH-47F Chinook pilot?

CAPT GOODRIDGE: Correct.

30
FLTLT ROSE: And that’s where you are today?

CAPT GOODRIDGE: Yes.

35 FLTLT ROSE: At paragraph 11 you state that you also qualified on the
Kiowa helicopter.

CAPT GOODRIDGE: Correct.

40 FLTLT ROSE: And the CT/4B. Is that a fixed-wing aircraft?

CAPT GOODRIDGE: Yes, that’s a – yes, it’s a fixed-wing.

FLTLT ROSE: You are currently the Troop Commander of 6 Medium

45 Lift Helicopter Troop in C Squadron in Townsville.

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 CAPT GOODRIDGE: Sorry, that probably is one amendment. I’ve only,
just in the last week or so, just handed that role over to my successor, but
that’s only since I signed this statement.
5
FLTLT ROSE: What is your current role now?

CAPT GOODRIDGE: I don’t necessarily have a position, as such, within

C Squadron, such as Troop Commander anymore, but I’m about to go on
10 to specialisation training as a Qualified Flying Instructor.

FLTLT ROSE: Will that be in Australia or overseas?

CAPT GOODRIDGE: The initial course is overseas.

15
FLTLT ROSE: When will you leave?

CAPT GOODRIDGE: In two weeks.

20 FLTLT ROSE: Will that be about a 12-month posting?

CAPT GOODRIDGE: No, the initial course is just three months. So I’ll
be back before the end of the year, and then I’ll be just in Townsville again
as a Qualified Flying Instructor next year.
25
FLTLT ROSE: Were you in the role of Troop Commander of 6 Medium
Lift Helicopter Troop in C Squadron as at 28 July 2023?

CAPT GOODRIDGE: I was.

30
FLTLT ROSE: In paragraphs 7 to 9 of your statement you outline that
you’re an A Category pilot, and a sixth year Captain.

CAPT GOODRIDGE: Correct.

35
FLTLT ROSE: And you are an Aircraft Captain for most tasks, unless
flying with a more senior pilot.

CAPT GOODRIDGE: Yes, correct.

40
FLTLT ROSE: At paragraph 11 you have a total of 1582 flying hours
across all of the three airframes you’re qualified on. That’s the CT/4B, the
Kiowa, and the Chinook.

45 CAPT GOODRIDGE: Correct.

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 FLTLT ROSE: I want to take you now to a course you attended in 2022 –
paragraph 16 of your statement. This is when you were the Troop 2IC at
C Squadron.
5
CAPT GOODRIDGE: Yes, correct.

FLTLT ROSE: You attended a Regimental Officers’ Intermediate Course

that was held at both Gallipoli Barracks and Oakey.
10
CAPT GOODRIDGE: Correct.

FLTLT ROSE: Gallipoli Barracks being in Brisbane.

15 CAPT GOODRIDGE: Yes.

FLTLT ROSE: And Oakey being a town near Toowoomba in Queensland.

CAPT GOODRIDGE: Yes, correct.

20
FLTLT ROSE: And the course was split between those two locations.

CAPT GOODRIDGE: Yes, it is. Yes, the first week – roughly a week –
is in Brisbane, and then the following two weeks is in Oakey.
25
FLTLT ROSE: In paragraph 18 you list the other Captains that were on
the course. Now, some of these persons have pseudonyms and some don’t.
I’ll start with those who don’t. If you can confirm that the following persons
were on this course: CAPT Benjamin Jackson?
30
CAPT GOODRIDGE: Correct.

FLTLT ROSE: Is he a fellow Chinook pilot from 5 Aviation Regiment?

35 CAPT GOODRIDGE: Yes. Yes, he is.

FLTLT ROSE: CAPT Campbell Rogan?

CAPT GOODRIDGE: Correct.

40
FLTLT ROSE: Is he another Chinook pilot from 5 Aviation Regiment?

CAPT GOODRIDGE: Yes, he is.

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 FLTLT ROSE: Then, if you look to the pseudonym list, was there a
Captain with the pseudonym of D129?

CAPT GOODRIDGE: Correct.

5
FLTLT ROSE: And that’s an MRH pilot from 6 Aviation Regiment?

CAPT GOODRIDGE: At that time, he was, yes.

10 FLTLT ROSE: Previous to that, was he at 5 Aviation Regiment?

CAPT GOODRIDGE: Yes, I believe he was. Yes.

FLTLT ROSE: D15?

15
CAPT GOODRIDGE: Correct.

FLTLT ROSE: Was he an MRH pilot from 6 Aviation Regiment?

20 CAPT GOODRIDGE: Yes, he was. Yes.

FLTLT ROSE: D55?

CAPT GOODRIDGE: Correct.

25
FLTLT ROSE: Was he, at that time, an MRH pilot from 5 Aviation
Regiment?

CAPT GOODRIDGE: Yes, he was, I believe.

30
FLTLT ROSE: Is he now at 6 Aviation Regiment?

CAPT GOODRIDGE: Yes, he is.

35 FLTLT ROSE: Then finally, CAPT Danniel Lyon?

CAPT GOODRIDGE: Correct.

FLTLT ROSE: He was the MRH pilot from 6 Aviation Regiment.

40
CAPT GOODRIDGE: Correct.

FLTLT ROSE: You say in your statement you think he was the Squadron
2IC in 2022.
45

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 CAPT GOODRIDGE: Yes, to the best of my recollection, he was the
Squadron 2IC at that time. I believe he was just about to step into a Troop
Command role the following year, I think, from memory.

5 FLTLT ROSE: You state at paragraph 12 that you did know CAPT Lyon
prior to this course as you’d met him in 2012 at ADFA.

CAPT GOODRIDGE: Yes, just briefly. He was – as I’ve said there, he

was two years above me at ADFA, so I didn’t know him well but I’d met
10 him just around – you know, through my time at ADFA there.

FLTLT ROSE: Had you ever flown with him?

CAPT GOODRIDGE: No.

15
FLTLT ROSE: At paragraphs 13 to 15 you outline that you’d never met
LT Max Nugent.

CAPT GOODRIDGE: Correct.

20
FLTLT ROSE: And you’d never met WO2 Phil Laycock.

CAPT GOODRIDGE: Correct.

25 FLTLT ROSE: And you’d never met CPL Alex Naggs.

CAPT GOODRIDGE: Correct.

FLTLT ROSE: Turning back to the course, the ROIC, at paragraph 19 you
30 state that there were some sessions on this course where you and your fellow
trainees got to speak with BRIG Dean Thompson.

CAPT GOODRIDGE: Correct.

35 FLTLT ROSE: He was the Commander of 16 Aviation Brigade at the

time.

CAPT GOODRIDGE: Yes, he was.

40 FLTLT ROSE: And LTCOL James Pidgeon.

CAPT GOODRIDGE: Correct.

FLTLT ROSE: Do you know what role he was in at that time?

45

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 CAPT GOODRIDGE: No, sorry I don’t recall.

FLTLT ROSE: And a COL Kim Gilfillan.

5 CAPT GOODRIDGE: Yes.

FLTLT ROSE: Do you recall what role he had?

CAPT GOODRIDGE: I believe he was DOPAW, but I’d have to confirm

10 that.

FLTLT ROSE: By “DOPAW”, do you mean the Director of Operational

Airworthiness?

15 CAPT GOODRIDGE: Correct.

FLTLT ROSE: These conversations were held at various times throughout

the week, and in both the classroom and at the Officers’ Mess.

20 CAPT GOODRIDGE: Correct.

FLTLT ROSE: At paragraph 20 you state that at one of these sessions you
recall CAPT Danniel Lyon talking about junior officers, and Army Aviation
being forced to fill positions, such as Command and Executive positions,
25 too early in their career, including Troop Commander, Squadron 2IC, and
Operations Officer.

CAPT GOODRIDGE: Yes, correct.

30 FLTLT ROSE: And that CAPT Lyon said he had concerns that they had
not been given sufficient time to develop their foundational flying skills
while in the Troop.

CAPT GOODRIDGE: Correct.

35
FLTLT ROSE: And that once they were in these Command positions, it
substantially reduced the time they had to fly because of the additional
administrative and supervision tasks they had to perform.

40 CAPT GOODRIDGE: Correct.

FLTLT ROSE: Do you recall if each of BRIG Thompson,

LTCOL Pidgeon and COL Gilfillan were in the room when CAPT Lyon
raised those concerns?
45

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 CAPT GOODRIDGE: I believe BRIG Dean Thompson and
LTCOL James Pidgeon were. I believe the conversation we had with
COL Kim Gilfillan was at a later date – I believe in the Officers’ Mess at a
later date.
5
FLTLT ROSE: Can you look at the pseudonym list and let me know
whether D9 was also present at any of these conversations?

CAPT GOODRIDGE: Yes, he was.

10
FLTLT ROSE: What role did D9 have?

CAPT GOODRIDGE: I believe he was the Brigade Major at that point.

15 FLTLT ROSE: Which conversations was D9 present for?

CAPT GOODRIDGE: He was mainly present for the conversations we

had with the Brigade Commander and LTCOL Pidgeon at that time in the
classroom, and then I believe he did come back and chat to us a couple more
20 times in the following weeks while we were at Oakey as well – just in our
classroom at Oakey, just to touch base with us again.

FLTLT ROSE: When CAPT Lyon was raising these concerns – we’ll start
with the ones that were during the class time which, as I understand your
25 evidence to be, was before BRIG Thompson, LTCOL Pidgeon and D9?

CAPT GOODRIDGE: Correct.

FLTLT ROSE: What was their response to CAPT Lyon’s concerns?

30
CAPT GOODRIDGE: So as I’ve sort of stated there, I don’t really recall
the specifics of what their responses were. I do just sort of recall them
respectfully taking the concerns on notice, though. We didn’t really expect
anything to come from those conversations. It was more just, as I
35 understand it, a forum for us to sort of air our thoughts and let the Brigade
Commander at that time sort of know what we’re feeling down to the Troop
level. So – yes.

FLTLT ROSE: Did you share CAPT Lyon’s concerns?

40
CAPT GOODRIDGE: I did. For the most part I did, yes. What he was
saying was, I think, true for his own circumstances, and true for the
circumstances of a lot of my peers. However, at that time I was still a Troop
2IC, and I was a Captain year 4, so I personally felt that I’d had enough
45 time to develop within the Troop before having to step into those higher-end

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 positions such as Troop Commander, or other staff positions. So it wasn’t
necessarily true for myself, but I could understand where he was coming
from.

5 FLTLT ROSE: Did you understand from CAPT Lyon’s concerns that he
thought there was a particular stage in a Captain’s career where they were
still too young to go into those roles? Did he have a specific level that he
was - - -

10 CAPT GOODRIDGE: Not that I can recall. I don’t recall him sort of
saying that it should be a certain Captain year, or anything like that, at that
time. Yes, I don’t recall him sort of making any comments like that.

FLTLT ROSE: Was that conversation heated in any way?

15
CAPT GOODRIDGE: It was passionate, I would say, but yes, it wasn’t
heated. It was still respectful, given the rank and who was in the room at
that time. So it was still respectful, but it was – yes, CAPT Lyon was
passionate in what he was saying.
20
FLTLT ROSE: Did anyone else – other trainees – raise similar concerns
during those classroom sessions?

CAPT GOODRIDGE: Yes, I think everyone was of similar opinions at

25 that time. Dan was definitely one of the more outspoken ones on the course,
so he tended to probably speak the most, I would say.

FLTLT ROSE: Did he ever say what he thought the consequences were of
people who were in positions higher than they should be, or not having
30 enough time to fly?

CAPT GOODRIDGE: I don’t recall him making comments about

consequences, no.

35 FLTLT ROSE: You referred to a separate conversation with

COL Gilfillan.

CAPT GOODRIDGE: Yes, we did have a separate conversation with

COL Gilfillan in the Officers’ Mess.
40
FLTLT ROSE: Was that during the – at Gallipoli Barracks?

CAPT GOODRIDGE: It was.

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 FLTLT ROSE: Do you recall if CAPT Lyon raised any concerns during
that conversation?

CAPT GOODRIDGE: I do recall there being discussions, and I think,

5 from memory, to the best of my recollection, it was along similar lines as
the previous conversations that we’ve talked about. But I don’t recall the
specifics of it, just due to the time that’s passed.

FLTLT ROSE: Do you recall whether that conversation was heated in any
10 way?

CAPT GOODRIDGE: I don’t believe so, no.

FLTLT ROSE: If my maths is correct – and tell me if I’m wrong – did you
15 get promoted to the Troop Commander role when you were about a
five-year Captain?

CAPT GOODRIDGE: Yes, correct. I was just at the end of my fourth

year, but stepping – my first year as Troop Commander was, yes, Captain
20 year 5.

FLTLT ROSE: The Inquiry has heard some evidence that Troop
Commanders don’t actually start getting the additional pay for fulfilling that
role until they’re a seven-year Captain.
25
CAPT GOODRIDGE: Correct.

FLTLT ROSE: So is that the same for you, you haven’t yet been paid for
the time – the additional pay for being a Troop Commander?
30
CAPT GOODRIDGE: Yes, correct. I should get that next year.

FLTLT ROSE: Even though you won’t be fulfilling the Troop

Commander role, you’ll step up to a further entitlement because that’s the
35 way - - -

CAPT GOODRIDGE: That’s my understanding, yes, as long as – my

understanding is as long as you’ve done 12 months as a Troop Commander,
you will then unlock that Captain year 7 pay bracket as a Troop
40 Commander.

FLTLT ROSE: Did that concern you whilst you were fulfilling the role as
Troop Commander, that you weren’t receiving the additional pay for it?

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 CAPT GOODRIDGE: Yes, to an extent. Yes, getting paid for the position
that you’re filling at the time would definitely be beneficial, I would say.

FLTLT ROSE: The cohort that you were with at the Regimental Officers’
5 Intermediate Course, had you discussed the concerns that CAPT Lyon was
raising with leadership amongst yourselves prior to the classroom
discussions?

CAPT GOODRIDGE: It was during – it was sort of during the course, I

10 guess, is – you know, after hours and things like that, that we would discuss
them as a course. So not necessarily prior to that particular conversation. I
can’t recall exactly which day. It could’ve been the first day of the course
or it could’ve been the fifth day of the course. So I can’t recall whether or
not we’d had time to, yes, talk about that amongst ourselves prior to those
15 conversations.

FLTLT ROSE: Was this a one-off occasion that you were given to share,
or voice concerns with the senior leadership in Aviation Command, or have
you been given other avenues to express concerns about either the
20 workload, the tempo, promotion to higher Command positions, pay,
anything like that?

CAPT GOODRIDGE: I wouldn’t say it’s a once-off. We do get those

opportunities at various times throughout the year. I think that one was
25 different because it’s not very often – I’ll say “very often”; we do get the
opportunity every now and then – but not very often that we get the
opportunity to have a one-on-one, you know, sort of frank conversation
with Brigade Commanders, for example; particularly in a small group
forum that’s not, you know, addressing a large room or something like that.
30
FLTLT ROSE: Do you recall being invited to join a town hall run by
KPMG at some stage in the recent couple of years to voice some concerns?

CAPT GOODRIDGE: I recall that occurring. I never attended it. I’m not
35 sure where I was at that time, but I never attended it.

FLTLT ROSE: Do you understand or recall what the purpose of that town
hall was for?

40 CAPT GOODRIDGE: No, sorry, I don’t, without referring to it.

FLTLT ROSE: Have you heard of snapshot surveys?

CAPT GOODRIDGE: I have.

45

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 FLTLT ROSE: What’s your understanding of what they are?

CAPT GOODRIDGE: So my understanding of a snapshot is that it’s a

survey that’s conducted, and it’s designed to be just a snapshot of that
5 particular day – or that particular point in time, to gather, you know, the
frustrations or what people are feeling within the Regiment, to inform the
Commanding Officer of that Regiment of, you know, how the people in his
Regiment – or his or her Regiment are feeling at that particular point in
time.
10
FLTLT ROSE: Is it run through the DFSB?

CAPT GOODRIDGE: I believe it is, yes.

15 FLTLT ROSE: Is it annual?

CAPT GOODRIDGE: Yes, I believe it is.

FLTLT ROSE: Have you participated or filled in a survey every year?

20
CAPT GOODRIDGE: I have, yes. Yes, I believe I have.

FLTLT ROSE: Do you get back briefed about the results of that survey?

25 CAPT GOODRIDGE: Yes, in my experience we have.

FLTLT ROSE: During those back briefs, has fatigue been a feature that’s
been discussed?

30 CAPT GOODRIDGE: I believe that’s usually one of the common themes,

yes.

FLTLT ROSE: Can you just elaborate on what exactly about fatigue is
discussed?
35
CAPT GOODRIDGE: I think, in general, it’s just – and, again, a
generalisation, but I think it’s people just feel at times potentially a little bit
burnt out, just given the workload that they’ve been under at that time.
That’s usually treated with a little bit of caution though because again, it is
40 a snapshot in time.

So if you’ve just come off the back of a very busy exercise period or
something like that where people are naturally going to be a little bit more
fatigued and the snapshot is run at that time, then that’s, you know,
45 potentially going to influence the results.

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 So, yes, sorry, I can’t really elaborate too much more than that.

FLTLT ROSE: What about in your own experience? Have you felt acute
5 fatigue or cumulative fatigue at any stages in your flying career?

CAPT GOODRIDGE: I definitely have, yes.

FLTLT ROSE: Is it something that is constant, or does it surge with the

10 exercise?

CAPT GOODRIDGE: For the most part, I think it surges with the
exercises and things like – you know, whatever is going on at that time. So
definitely the build-up, and then the conduct of the exercise, is usually, you
15 know, a busier period; particularly, in C Squadron. And again in
C Squadron, because that’s my experience, we have a fairly – you know, a
reasonably high tempo for the majority of the year, I would say. So that
also does tend to take its toll over time as well.

20 FLTLT ROSE: So there are obviously surge periods, as you’ve just said.
Is there adequate periods of rest to recover from those intense periods?

CAPT GOODRIDGE: There is, I believe. We have the reduced tempo

periods, which, for 5th Aviation Regiment, usually align with the school
25 holiday periods, and that type of thing, where people are definitely
encouraged to take leave. Some people may not choose to because of
whatever reason. They might want to save their leave up to take a larger
holiday at the end of the year, or they might want to take holidays at other
times throughout the year.
30
So not everyone, I would say, uses those periods. It also depends on what
– I think it also depends on what position you’re filling because sometimes,
just with the nature of our business, an exercise period may be immediately
after a reduced tempo period, for example, and those dates may not be able
35 to be changed. So if you’re in a key role or a key position that is required
to conduct some sort of lead-up planning or preparation for that exercise,
that may impact your ability to take leave during that reduced tempo period.

There is usually always though a little bit of a stand-down period, or a few

40 days at least after the exercise where everyone is sort of encouraged to take
some leave.

FLTLT ROSE: Are you aware of any tool that Aviation Command uses
for pilots to be able to assess their own fatigue levels prior to a crew duty
45 starting or a sortie?

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 CAPT GOODRIDGE: Yes. So we have our FACE checks, which has now
just recently been replaced by a tool, a Fatigue Tool I guess, that we use,
and we brief that – at least in C Squadron, we brief that prior to every flight,
5 or during the orders for every flight.

FLTLT ROSE: This Fatigue Tool, is it a DFSB-issued Fatigue Tool?

CAPT GOODRIDGE: I would have to check who actually issued it, to be

10 honest.

FLTLT ROSE: Is it a series of short questions that ask you about your
sleep and rest?

15 CAPT GOODRIDGE: Yes, for the most part. Yes.

FLTLT ROSE: And then about the type of tasks you’re undertaking?

CAPT GOODRIDGE: Yes, and it’s just – my understanding is it’s just

20 aimed to give you an understanding of how you may be feeling that day and
whether you have ambers or reds or that type of thing, as the tool sort of
comes out with.

FLTLT ROSE: Could I have the witness shown Exhibit 37.

25
MS McMURDO: Yes.

FLTLT ROSE: Also, I believe we have a copy of Exhibit 37 to put on the

screen. Is this the Fatigue Tool you were referring to?
30
CAPT GOODRIDGE: Yes, it is.

FLTLT ROSE: You’ll see in the top left-hand corner it says “DFSB”.

35 CAPT GOODRIDGE: Yes, correct.

FLTLT ROSE: If you look down at the bottom right-hand corner, it says
“Version 1, 10 November 2020”.

40 CAPT GOODRIDGE: Yes, I can see that.

FLTLT ROSE: When was the first time you saw this document in
C Squadron?

45 CAPT GOODRIDGE: Probably late last year, if I’m being honest.

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 FLTLT ROSE: November/December?

CAPT GOODRIDGE: Yes, late last year. Sorry, I don’t recall specific
5 dates.

FLTLT ROSE: Have you received any specific briefing on how to use this
tool?

10 CAPT GOODRIDGE: We did receive, just within the Squadron, a small

brief – a short brief, I should say – on sort of how to use, as it sort of began
to take over what we’d always been using previous to that, which was the
FACE checks, yes.

15 FLTLT ROSE: Did you use this every time before you do a sortie?

CAPT GOODRIDGE: Yes. So it’s now a requirement, as I understand it,

a requirement for everyone to complete this before they fly.

20 FLTLT ROSE: You say “a requirement”. Is it in policy?

CAPT GOODRIDGE: I believe it is. I’d have to check which policy it’s
in.

25 FLTLT ROSE: Where do you record the results of this?

CAPT GOODRIDGE: My understanding is that we’re not required to

record the results of it. It was just a requirement that we conduct it and that
we brief our results during – yes, brief our results during the orders for that
30 flight.

FLTLT ROSE: So if you’re conducting two sorties in a day, you’d do it

before each sortie?

35 CAPT GOODRIDGE: It depends. In C Squadron, it’s quite rare that we

would do two sorties in a day. Our sorties are usually of a three to four-hour
length, so we don’t normally have time in a day for two separate sorties. I
would say though that if you’re conducting two separate sorties in a day
that are separate missions – we’ll call it – then, yes, you should complete
40 that prior to each. Any time you conduct a new set of orders for a mission,
then you should conduct this tool, or you should brief this tool.

FLTLT ROSE: So do you and your fellow crew members get a pencil or
pen out and tick the boxes?
45

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 CAPT GOODRIDGE: It’s up to individuals how they want to use it.
Some individuals choose to print them off, I believe, and might choose to
tick and flick. Others might just choose to use it as a reference tool, just to
read through it and, you know, visually sort of identify where your fatigue
5 may be.

FLTLT ROSE: Then you say you brief it at mission orders?

CAPT GOODRIDGE: Correct.

10
FLTLT ROSE: Is that to a particular Command?

CAPT GOODRIDGE: It will usually just be to the Aircraft Captain, so it’s

mainly just to identify if anyone had any concerns, or that this awareness
15 tool raised any concerns that they think that the crew should know about,
and it’s briefed to the Aircraft Captain, and usually the Authorisation
Officer will be somewhat aware of that as well.

FLTLT ROSE: Have you ever been in a situation where you, or any of
20 your fellow crew, have been in the amber or red section?

CAPT GOODRIDGE: I have had some – yes, there are some people that
have ambers at times. I’ve never personally been in a situation where
someone has said that they were red for anything.
25
FLTLT ROSE: What happened when someone said they were amber?

CAPT GOODRIDGE: It could be a whole – it could be any number of

things, really. Sorry, are you talking about the consequences?
30
FLTLT ROSE: What the consequences of being amber are?

CAPT GOODRIDGE: Usually it depends what it is. Usually, we’d just

have a chat about it. In my experience anyway, we’ll have a chat about it
35 during the orders for that mission and ask that person how they’re feeling
and if they’ve got any concerns, or if they have any concerns with
conducting that particular flight.

Then in my experience, personally, as an Aircraft Captain, I will usually

40 make sure that that person – I’ll have a chat with that person and make sure
that they, you know, feel empowered, I guess, to speak up at any time
throughout the flight; particularly if it’s something to do with, you know,
potentially not getting enough sleep the night before or something like that.
That if they start to feel fatigued during that flight, that they let us know and
45 we can adjust the sortie profile, or cancel it and come home.

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 FLTLT ROSE: So there’s no requirement in the policy that if somebody
is amber, they’re not to fly that day?

5 CAPT GOODRIDGE: I am – not to my understanding, but I would have

to check the policy to be sure of that.

FLTLT ROSE: Do you see on the right-hand side page where it says when
someone is amber, to actively manage them? Do you see there?
10
CAPT GOODRIDGE: Yes, in the black. Yes, I do.

FLTLT ROSE: It says:

15 Advise your supervisor of your heightened fatigue risk and ask

team members to monitor you. Consider adjusting tasks. Increase
team communication and task cross-checking. Consider taking a
break or accessing controlled rest/napping. Consider strategic use
of caffeine and food intake.
20
CAPT GOODRIDGE: Yes, I can see that.

FLTLT ROSE: So you’ve just given some evidence that you might adjust
the tasks if somebody is feeling - - -
25
CAPT GOODRIDGE: Yes, correct. So what’s written there is basically,
in my experience, exactly what we would do within C Squadron. So, yes,
if someone was genuinely feeling tired or fatigued for whatever reason, we
would make sure that person feels empowered to speak up at any time
30 throughout the flight if they are feeling, you know, drowsy or anything like
that. Absolutely, we can always – depending on what the nature of the task
is, but there’s usually always room to amend the profile of the flight to
potentially end early, or to move that member to a different crew station,
for example.
35
FLTLT ROSE: So if I understand your evidence, the crew member has
already willingly identified that they’re in the amber?

CAPT GOODRIDGE: Correct.

40
FLTLT ROSE: Then the sortie still goes ahead and it’s still on that
particular crew member to then manage it? It’s not on the supervisor to
start taking over the management of their fatigue for them?

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 CAPT GOODRIDGE: To an extent, the onus is on the member to identify
and raise if they have concerns, at least from my experience. If they have
concerns and they raise that they, you know, would appreciate – or that they
would like the flight to be cancelled and brought home early, or that they
5 would like to be moved to a different crew station, for example, then that
onus then really comes down on the Aircraft Captain to actually enforce
those changes at that time.

FLTLT ROSE: So it’s not the situation where an amber is identified and
10 the Authorisation Officer or the Aircraft Captain actually are then obliged
to take that crew member out of that role and put them in a different role?

CAPT GOODRIDGE: No, not that I’m aware of, no. It’s all
situation-dependent at that time.
15
FLTLT ROSE: Do you understand what “strategic use of caffeine and
food intake” means?

CAPT GOODRIDGE: I could take a stab at it, but I wouldn’t – without

20 referencing the policy behind it, I wouldn’t - - -

FLTLT ROSE: So you haven’t been briefed on what that means, haven’t
been given guidance?

25 CAPT GOODRIDGE: No, I don’t recall being briefed on strategic use of

caffeine, no.

MS McMURDO: What would you think it means if you were

implementing these?
30
CAPT GOODRIDGE: Ma’am, so I would say that it’s just a case of – as
we all know, caffeine can help to keep you awake and reduce the effects of
fatigue, at least for a period of time. So I’d say that if someone is feeling
just a little bit drowsy that morning or something like that, that they should
35 be encouraged to go and – if they want caffeine, then they should be
encouraged to go and - - -

MS McMURDO: Have a caffeine drink?

40 CAPT GOODRIDGE: Yes, exactly, yes, prior to the flight, to try and
wake them up a little bit.

MS McMURDO: What about the food intake?

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 CAPT GOODRIDGE: That one I would say just comes down to, you
know, again, the fatigue and that sort of thing, and energy levels, I guess.
So making sure that people have actually had breakfast or a snack or
something before they actually go flying and they’re not flying on an empty
5 stomach for a full-hour flight, ma’am.

MS McMURDO: So you mentioned that this came into effect in late 2023,
as far as you can recall.

10 CAPT GOODRIDGE: Yes, as far as I can recall, ma’am, yes.

MS McMURDO: Roughly since that time that this has come into effect,
how many flights would you have conducted? Just a ballpark figure?

15 CAPT GOODRIDGE: For myself, ma’am?

MS McMURDO: Yes, yourself.

CAPT GOODRIDGE: I would say 30 to 50 flights for myself.

20
MS McMURDO: Sure. In all that period, no one’s ever come up with a
red?

CAPT GOODRIDGE: Not in my experience, no.

25
MS McMURDO: No. A few times there’s been an orange.

CAPT GOODRIDGE: Correct.

30 MS McMURDO: But never to the point where they’ve said they didn’t
want to fly.

CAPT GOODRIDGE: Correct.

35 MS McMURDO: You say then you would actively manage it. Do you
ever recall during the flights on those occasions, the people who did identify
as orange asking for you to manage it in a certain way because they’re
feeling a bit tired?

40 CAPT GOODRIDGE: In my experience, no, I don’t recall ever having

someone during the flight – outside of what was briefed during the orders –
during the flight, raising that they are feeling exceptionally drowsy or
fatigued at that time, and that they would like to be sort of managed or
moved to a different station or something.
45

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 MS McMURDO: Thank you. Yes, FLTLT Rose, thank you.

AVM HARLAND: Just to follow on from that, has the introduction of this
DFSB Fatigue Risk Awareness Tool materially changed the way that
5 fatigue management is addressed at the unit?

CAPT GOODRIDGE: My understanding is it hasn’t, at least in

C Squadron and 5th Aviation Regiment. I don’t believe it’s changed the
way we manage or deal with fatigue to a great extent, no. I think this is just,
10 in my experience, a new tool that really covers off on the same things that
we were covering off prior to the introduction of this tool.

AVM HARLAND: Thank you.

15 FLTLT ROSE: Do you think there is an expectation or attitude within

aviators in Army Aviation, particularly C Squadron, to just complete the
task, push through fatigue to get the task done?

CAPT GOODRIDGE: That is something that can creep in from time to

20 time, yes. But I will say that usually we are quite aware of that as well. I’d
say the vast majority of missions that we do – or flights that we do, are just
in training. So we do try to sort of reinforce that, that we are only in training
at the end of the day, and we try not to let those pressures, I suppose, creep
into the flight where we can. But, inevitably, they always do, to a certain
25 extent.

FLTLT ROSE: Do C Squadron fly in that circadian low period between

2 am and 6 am?

30 CAPT GOODRIDGE: No, not regularly. Yes, very rarely we would fly
between those periods.

FLTLT ROSE: At paragraph 23 you set out some evidence reflecting on

whether the issue that CAPT Lyon raised at the ROIC in 2022 still exist
35 within Army Aviation today.

CAPT GOODRIDGE: Yes, correct.

FLTLT ROSE: What are your views about that?

40
CAPT GOODRIDGE: So as I’ve said there, I believe they do still exist.
So again, in my personal experience, it’s not necessarily what I have seen
for myself. As I’ve said, I was allowed four years to develop in the Troop
prior to stepping into Troop Commander as a Captain year 5, at which point
45 I felt well prepared to take on the role and the additional responsibilities,

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 and I felt that I’d had the opportunity to develop my flying skills to the point
that I thought I needed to. But I have also seen some of my peers step into
positions such as Troop Commander or other staff positions as early as a
Captain year 2 or 3. So I think they definitely do still exist, yes.
5
FLTLT ROSE: Why is it that you think someone would be promoted to
that Command position at year 2 or 3? Is there a need for them to go into
that role?

10 CAPT GOODRIDGE: Yes. So in my experience, that’s all it is. Those

positions are positions that are crucial to the running of the Squadron or the
Troop. So the position needs to be filled and, in my experience, it’s just
simply a case of that member who may be required to step into that role
early is simply the most appropriate person to step into that role at that time,
15 or there may be simply no one else above them who is more senior to be
able to step into that role. So they’re simply the next one in line, basically,
and they have to just step into that role.

MS McMURDO: So it’s a shortage of qualified people? It really comes

20 down to that?

CAPT GOODRIDGE: To an extent, ma’am, yes. I’m unsure of what

causes the shortages and things like that, but it’s quite often the case. Well,
not “quite often”, but it’s sometimes the case that just there’s no one else
25 above that person because they’ve moved on to specialist training, such as
QFI or something like that, or they’ve transferred to a different Regiment,
or they chose to leave Defence Force, or whatever reason.

AVM HARLAND: How is your experience as a Troop Commander in

30 terms of workload and fatigue?

CAPT GOODRIDGE: It’s a busy role. Particularly my experience in

C Squadron, it’s a busy role. It’s a busy time. We’re quite often out the
door doing different activities and we’re often supporting numerous other
35 ground units. So it’s busy. I would say it’s manageable, from my
experience. As I’ve said, I’ve just handed over, so I’ve spent almost
two years as a Troop Commander. I think I managed it okay. There’s
things I could have done better. But, yes, I think it’s manageable.

40 AVM HARLAND: Thank you.

FLTLT ROSE: Could I just ask that that Exhibit 37 be taken down off the
video screen. I’m going to move to a different topic now, and it’s about
Exercise TALISMAN SABRE 2023. I take it from your statement, you
45 weren’t deployed on that exercise?

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 CAPT GOODRIDGE: No, I wasn’t.

FLTLT ROSE: You were on leave from your Squadron at that time as you
5 had just completed another exercise just prior to Exercise TALISMAN
SABRE?

CAPT GOODRIDGE: Yes, that’s correct. So I was the Troop

Commander for the two exercises that led up to TALISMAN SABRE, and
10 then I handed off the role of Troop Commander to CAPT Campbell Rogan
for the conduct of TALISMAN SABRE.

FLTLT ROSE: So does that mean you were effectively on leave from the
ADF on 28 July 2023?
15
CAPT GOODRIDGE: I was. Yes, I was on leave.

FLTLT ROSE: So you didn’t play a part in the search and rescue for the
Bushman 83?
20
CAPT GOODRIDGE: No, I didn’t.

FLTLT ROSE: Those are my questions.

25 MS McMURDO: Thank you. Are there any applications to cross-

examine? No.

Thank you very much, CAPT Goodridge.

30 CAPT GOODRIDGE: Thanks, ma’am.

MS McMURDO: I appreciate your coming and giving your evidence.

CAPT GOODRIDGE: Thanks, ma’am.

35
MS McMURDO: You can leave now. Thank you.

CAPT GOODRIDGE: Thanks, ma’am.

40
<WITNESS WITHDREW

FLTLT ROSE: The next witness has a pseudonym, so the camera to the
45 witness box will be disconnected now.

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 MS McMURDO: Yes. I will remind everybody that no images of this
person are to be shown, and only a pseudonym is to be used.

5 COL STREIT: Good morning, Ms McMurdo, AVM Harland. I will be

taking the next witness and the witnesses this afternoon. Can I indicate for
the assistance principally of Counsel representing, that I don’t intend to go
into a private hearing in respect of any of the witnesses to be called today.
I will deal with matters publicly. But if any Counsel representing consider
10 they need to go into a private hearing to ask questions in relation to
witnesses this afternoon, I ask that they raise that with me during the lunch
break.

MS McMURDO: Yes, thank you, COL Streit.

15
CLERK OF THE COURT: Do you want to take the oath or affirmation?

D129: Affirmation.

20
<D129, Affirmed

<EXAMINATION-IN-CHIEF BY COL STREIT

25

COL STREIT: Can I just confirm with the Secretary that the video screen
is only internal?

30 CLERK OF THE COURT: It’s only internal; it’s not (indistinct).

COL STREIT: Good morning, D129.

D129: Good morning, sir.

35
COL STREIT: Now, can I just ask you some questions, just some
preliminary matters, if I may? First, do you recall receiving a section 23
Notice to be here today?

40 D129: I did.

COL STREIT: Did you also receive a Witness Frequently Asked

Questions Guide?

45 D129: I did.

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 COL STREIT: A Privacy Notice?

D129: I did.
5
COL STREIT: An extract of this Inquiry’s Directions?

D129: I did.

10 COL STREIT: Now, as a consequence of receiving the section 23 Notice,

did that contain some questions and ask you to provide a statement for this
Inquiry?

D129: Yes, it did.

15
COL STREIT: Before we turn to that statement, can I just remind you of
your security obligations, and that if I ask a question, or anyone asks a
question, where you feel that might be entering a classification higher than
“Official”, can you just indicate that to me or the person asking the question.
20 We might need to deal with that matter in a private session.

D129: Yes, I will, sir.

COL STREIT: What I’m going to do now is just show you a document.
25 I’ll just give you an opportunity to look through it.

MS McMURDO: Could you also ask the witness to have a look at the
pseudonym list and confirm who he is on that?

30 COL STREIT: Just about to do that, ma’am.

D129: Yes, that’s my statement.

COL STREIT: Thank you. Now, there is a sheet next to you. If you just
35 turn that over? Just go to D129. Could you just indicate to that, whether
the name that is adjacent to the pseudonym, is that you?

D129: Yes, that’s me.

40 COL STREIT: Now, you’ve had the opportunity, have you, before giving
evidence today, to compare your statement to that pseudonym list - - -

D129: Yes, I have.

45 COL STREIT: - - - in relation to where your statement has been redacted?

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 D129: Yes, I have.

COL STREIT: And are you satisfied that where your statement has been
5 redacted and refers to a pseudonym, that accords with the correct name in
the pseudonym list?

D129: Yes, I can confirm that.

10 COL STREIT: Thank you. Is there anything you wish to change or amend
in your statement?

D129: No, there isn’t.

15 COL STREIT: Now, your statement comprises a series of paragraphs and

two annexures; is that right?

D129: That’s correct.

20 COL STREIT: Now, is my understanding correct that you are content for
the entirety of the information in your statement to be given in a public
hearing

D129: That’s correct.

25
COL STREIT: I tender – sorry, can you just identify for me the date of
your statement, please?

D129: 24 July 2024.

30
COL STREIT: Thank you. And I tender D129’s statement of that date.

MS McMURDO: It’s Exhibit 46.

35
#EXHIBIT 46 - STATEMENT OF D129 DATED 24/07/24

COL STREIT: What I’m going to do now is just ask you some questions
40 in relation to your background, and where I deem it appropriate I’ll read
parts of your statements out onto the record and I’ll just simply ask you to
confirm as to what I said is correct or not.

D129: Okay.
45

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© C’wlth of Australia
 COL STREIT: You joined the Australian Army in January 2013 as a
General Service Officer?

D129: Yes, that’s correct.

5
COL STREIT: You entered through the Australian Defence Force
Academy with an Aviation Cadetship, studying science; is that right?

D129: Yes, that’s correct.

10
COL STREIT: In 2015, you transferred to the Specialist Service Officer
career stream and you commenced flying training post your first SSO of
first appointment course; is that right?

15 D129: Yes, that’s correct.

COL STREIT: The first appointment course, that was conducted at the
Royal Military College Duntroon?

20 D129: Correct.

COL STREIT: You graduated Basic Flying Training in Tamworth in

early 2016, and then proceeded to the Army Helicopter School at the Army
Aviation Training Centre; is that right?
25
D129: Correct.

COL STREIT: You graduated from that course in July 2016, spending
six months in Graduate Pilot Troop?
30
D129: Correct.

COL STREIT: What’s Graduate Pilot Troop? What do you do there?

35 D129: It’s essentially a Troop which you hold while you wait for your
operational-type transition continuing to fly Kiowa as a qualified pilot
versus a trainee.

COL STREIT: Thank you. In 2017, you completed and graduated from
40 the MRH-90 Initial Employment Training operational-type transition
before posting to A Squadron, 5th Aviation Regiment in Townsville in
2018. Is that right?

D129: Correct.
45

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 COL STREIT: You posted to 6 Aviation Regiment in Sydney in
January 2021?

D129: Correct.
5
COL STREIT: And you currently remain posted at that unit?

D129: That’s correct.

10 COL STREIT: Now, you’ve worked in a variety of roles, including

Regiment and Squadron operations, Training Cell and Technical Adjutant?

D129: That’s correct.

15 COL STREIT: And you’ve participated in exercises, non-warlike

operations and Defence aid to the civil community in your Military Service?

D129: Correct.

20 COL STREIT: In terms of Defence aid to the civilian community, are

there any particular examples come to light?

D129: Yes, sir. There was North Queensland floods, NSW floods, the
bushfires as well of 2019/2020.
25
COL STREIT: And what was your role in that aid to the civilian
community?

D129: The North Queensland floods and the bushfires was as an MRH-90
30 pilot, and then the NSW floods in 2022, it would have been – was in an
Operations Officer type capacity.

COL STREIT: And in terms of those particular roles as an MRH-90 pilot

you’ve just referred to, what type of taskings were you required to
35 undertake?

D129: So for floods it was predominantly moving equipment, supplies,

that sort of thing, to communities that had been cut off. A lot of the work
during the bushfires was fire mapping. So taking somebody from a rural
40 fire service by day and night and just mapping the fire lines, that sort of
thing.

COL STREIT: On any of those Defence aid to the civilian community

tasks, did you need to be recalled from leave?
45

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 D129: Yes, I believe I did, during the bushfires, if I recall correctly.

COL STREIT: “The bushfires”, what’s that a reference to?

5 D129: That was the bushfires of late 2019, early 2020.

COL STREIT: In New South Wales or somewhere - - -

D129: I participated – there were some in Queensland and then there were
10 some in Victoria that I was deployed to as well.

COL STREIT: Sure. Now, if we just turn the page, at paragraph 3, you
competed training on a fixed-wing aircraft at Basic Flying Training School
2015-2016 before you conducted your helicopter qualification course. Is
15 that right?

D129: That’s correct.

COL STREIT: Graduated on a Kiowa Bell 206B helicopter; correct?

20
D129: Correct.

COL STREIT: Now, para 4, you’ve completed Black Hawk conversion

training, recently attained Special Operations co-pilot qualification on
25 Black Hawk?

D129: That’s correct.

COL STREIT: Turning to para 5, you posted to the 6 Aviation Regiment

30 and you were in the S73 training role as at 28 July 2024.

D129: That’s correct.

COL STREIT: If you can just explain what the S73 role is that you
35 undertake?

D129: So that role in the Training Cell acts as the 2IC of the Training Cell
which is held at the Regiment Headquarters’ level. The primary duties of
that are around ensuring that training is planned, organised and executed.
40 And that sort of training might be something simple, as the mandatory
training period at the start of the year. And at the time that I was in that
role, that cell also planned and ran the SOQC suite of courses as well.

COL STREIT: Just in terms of the date, you’ve got 2024; is that correct?
45

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 D129: Sorry, that should be 2023.

COL STREIT: All right, thank you. So I’ll read para 5, first sentence, is
this:
5
I was posted to the 6th Aviation Regiment and was in the S73
(Training Cell) role as at 28 July 23.

D129: That’s correct.

10
COL STREIT: Now turning to paragraph 6. You’ve been posted to the
6th Aviation Regiment as a Troop Pilot, and 173 Special Operations
Aviation Squadron in 2021.

15 D129: That’s correct.

COL STREIT: You were a line pilot, were you, at that time?

D129: Yes, in 2021 I was a line pilot.

20
COL STREIT: You’ve been the Regiment S35 Operations Officer Future
Plans in 2022.

D129: Correct.
25
COL STREIT: Now, just explain briefly what that role was?

D129: That role was predominately focused on looking, you know, three
to 12 months out at any exercises/activities that the unit was conducting and
30 doing all the initial planning for that. In 2022, at that time the SOQCs were
also being predominately planned by the S35.

COL STREIT: You then say, at paragraph 6, you were the Technical
Adjutant and S73 in 2023. Is that right?
35
D129: Correct.

COL STREIT: What’s the “Technical Adjutant”? What’s that role?

40 D129: The Technical Adjutant looks after identifying and facilitating any
capability gaps in the unit, and then working with 16 Brigade, DACM, to
come up with solutions to fix any capability gaps or introduce solutions or
equipment that make the job easier, essentially.

45 COL STREIT: You then say further at para 6 that you’re now the

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 Operations Officer of 171 Special Operations Squadron. Is that right?

D129: That’s correct.

5 COL STREIT: In broad terms, what’s your role as the Operations Officer?

D129: The role of the Operations Officer leads the Squadron Operation
Cell, which includes a mix of people from Intelligence, Mission Support,
other aircrew. And their primary role is the analysis, planning, execution
10 of all the Squadron’s operations and activities at the direction of the OC.

COL STREIT: Now, at paragraph 6(b), if I could just take you to that? In
terms of your role in 2022, the second-last sentence, you say:

15 Additionally, I was the Troop Commander of Special Operations

Crash Response Troop over that period.

D129: That’s correct.

20 COL STREIT: So you held a Command appointment in 2022?

D129: Yes. The Special Operations Crash Response Troop, traditionally

the Troop Commander of that Troop has been the S35 as an additional role
for them.
25
COL STREIT: I don’t want you to – I’m not going to ask you any
questions about capability, but in broad terms can just explain what the role
of the Special Operations Crash Response Troop is?

30 D129: So they serve both an operational role and a training safety role. So
in training operations, they will be part of the landing zone party, and that
is a group of Crash Response Specialist, medical personnel, and
communicators and Commanders that are there to respond to any incidences
that may occur at the LZ during training. And then, in an operational role,
35 they’re focused on recovery of downed aircraft and personnel.

COL STREIT: Did you have to undertake any particular search and rescue
training to undertake that role as the Troop Commander, or is it on-the-job
training?
40
D129: No, it’s on-the-job training. But as their Troop Commander, I was
not involved in any technical aspects of that Troop.

AVM HARLAND: Did the SOCRT, the Special Operations Crash

45 Response Troop, have any role to play in ADF exercises?

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 D129: Yes, sir, they did. So any time we conduct Special Operations
Aviation Missions it is a requirement that the CRT are present at any
landing zones that we’re using.
5
AVM HARLAND: Are you aware if that was the case on TALISMAN
SABRE ‘23?

D129: They were certainly up there. As for their exact location, I’m not
10 sure. But it would have been whatever the LZ or the target LZ for the day
was.

AVM HARLAND: Thank you.

15 COL STREIT: At paragraph 6(c) you set out some evidence in relation to
your role as the Technical Adjutant, and you say, in the second sentence:

The focus of the role was being the link between 6 Aviation
Regiment, 16 Aviation Brigade, and Directorate of Aviation
20 Capability Management, among other external agencies.

So in that role in 2023, January to June, do you recall having that level of
engagement between those different levels of Command?

25 D129: Yes, so occasionally there was. It was predominantly about minor

equipment issues relating to iPad devices we might have used in the aircraft,
and kneepad devices. There’s some stuff about caving ladders and repair
of those items. That was mostly it.

30 COL STREIT: Your primary role, July to December 2023, was the S73,
which you’ve set out at paragraph 16. Is that correct?

D129: Correct.

35 COL STREIT: In paragraph 7 you have the following qualifications:

Special Operations co-pilot MRH-90, March ‘21?

D129: Correct.

40 COL STREIT: Your Special Operations Captain MRH-90, November

2022?

D129: Correct.

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 COL STREIT: You’re currently a Special Operations co-pilot UH-60M
as of July this year.

D129: Correct.
5
COL STREIT: The UH-60M is Black Hawk?

D129: Correct.

10 COL STREIT: You’re currently a Category C pilot on the Black Hawk?

D129: Correct.

COL STREIT: You hold a Command Night-Vision Imaging System

15 rating and a Command Instrument rating.

D129: That’s correct.

COL STREIT: You are presently a fifth year Captain.

20
D129: That’s correct.

COL STREIT: Can I just ask you, when you held the role of Troop
Commander of the Special Operations Crash Response Troop in 2022, were
25 you a fourth year Captain at that time?

D129: I would have been a third year Captain.

COL STREIT: Third year. And did you receive any extra pay for having
30 that command responsibility?

D129: No.

COL STREIT: Do you know if you had been a Captain of greater

35 seniority, do you know if you would have received extra pay?

D129: No. The extra Troop Commander pay applies to Aviation Troops
that fly helicopters. So this Troop was not an Aviation Troop and, therefore,
didn’t attract that extra pay.
40
COL STREIT: Did you fly helicopters, though, when you were in that
Troop?

D129: Yes, I personally flew helicopters. However, the SOCRT do not

45 operate helicopters.

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 MS McMURDO: Are you keeping your currency, your – were you still
flying during that time?

5 D129: Yes, ma’am. During that role, I was flying as normal.

MS McMURDO: As normal. Yes. Thank you.

COL STREIT: You’re currently an Aircraft Captain on the Black Hawk

10 by day and night for non-Special Operations missions?

D129: Correct.

COL STREIT: Your current role, as you sit here today, is the Operations
15 Officer of 171 SOAS Squadron?

D129: That’s correct.

COL STREIT: At paragraph 12 you set out the role of the Operations
20 Officer, and I won’t – it’s not necessary for me to lead that evidence from
you. I just want to now turn to your hours in relation to MRH-90 Taipan as
they were when that aircraft was in use. So you had a total flying hours of
1105.4 hours in aircraft. Is that right?

25 D129: That’s correct.

COL STREIT: You had 141.1 hours sim?

D129: That’s correct.

30
COL STREIT: Day hours, 751.9 hours; correct?

D129: Yes, correct.

35 COL STREIT: Seventy-four hours sim?

D129: Yes, correct.

COL STREIT: The night hours were 353.5?

40
D129: Correct.

COL STREIT: Sim was 67.1?

45 D129: Correct.

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 COL STREIT: Night-vision device, 310.6 hours?

D129: Correct.
5
COL STREIT: And the sim was 15.6 hours?

D129: Correct.

10 COL STREIT: The NVD, is that TopOwl?

D129: Yes, that was on TopOwl.

MS McMURDO: Was that also part of the night hours? So is that not an
15 additional figure but, rather, that would have been - - -

D129: That’s correct, ma’am. So the night hours include both night-vision
device and night-unaided hours.

20 MS McMURDO: So 4 is just really a subset of 3?

D129: Correct, ma’am, yes.

MS McMURDO: Thank you.

25
COL STREIT: You’ve spent approximately 246 hours in formation
flying?

MS McMURDO: In MRH-90, that’s correct.

30
COL STREIT: MRH-90. It’s not necessary I deal with Black Hawk;
you’ve set it out in your statement. I take you to paragraph 13. You say:

Aviation Command released a number of Special Flying

35 Instructions that have placed additional requirements,
considerations and restrictions around Night-Vision Imaging
System flight, fatigue management, and formation and terrain
flight, and degraded visual environment flying, currency
requirements.
40
Just in relation to fatigue management, was there a change in relation to
what you needed to do as a pilot coming into the work environment at the
end of last year in terms of needing to complete a particular fatigue
awareness tool?
45

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 D129: Yes. So the Fatigue Risk Awareness Tool was started to be used
towards the end of last year. However, I was not yet flying at that stage, so
I wasn’t completing that tool at the time.

5 COL STREIT: Do you recall when you first became aware of the
requirement to use that tool for flying?

D129: It would have been towards the end of 2023 and then I didn’t
commence using it until I think it was March/April this year, when I
10 recommenced flying on Black Hawk.

COL STREIT: Can you just explain what your understanding is of the
purpose of the tool?

15 D129: It has a series of questions – five or six questions. They relate to

your sleep time over the last 24-48 hours, your – sort of level of alertness,
alongside how long you would be working and how long you’d be awake
at the end of your period of duty. It’s broken down into a green, amber, red
light system, and it’s meant to provide you, your crew and the Authorising
20 Officer with some awareness of your fatigue state.

COL STREIT: Can the witness be shown Exhibit 37, please? I just ask if
Exhibit 37, or the Fatigue Awareness Tool, could be placed on the screen.
Exhibit 37 is before you. Is that the Fatigue – just tell me the title of it.
25
D129: Fatigue Risk Awareness Took. Yes, it is.

COL STREIT: Thank you. Shortened to FRAT?

30 D129: To FRAT.

COL STREIT: But that Fatigue Risk Awareness Tool, is that the tool
you’re referring to in your evidence you’ve just given?

35 D129: Yes, it is.

COL STREIT: Do you find it a useful tool?

D129: I do find it useful, yes.

40
COL STREIT: Do you find it’s something that has enhanced, from your
perspective, in any event, identifying the risk of fatigue in aircrew about to
undertake Aviation tasks?

45 D129: Yes. I believe it assists in identifying, yes.

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 COL STREIT: Can you just explain, did you receive any training on the
use of the tool or how to complete it?

5 D129: No specific training, no.

COL STREIT: Your use of this particular tool now, when you’re
undertaking your preparation for flight, you complete it yourself?

10 D129: Yes, that’s correct.

COL STREIT: Do you need to complete it in the presence of anyone or

are you completing it on your own?

15 D129: You complete it on your own via an electronic system and it’s
stored in a folder. It’s then communicated to your Aircraft Captain and your
Authorising Officer as well.

COL STREIT: So your understanding is they receive a copy of your

20 completed Fatigue Risk Awareness Tool?

D129: It’s not sent to them; they have access to it should they want to view
it. And then you verbally tell them your series of greens, reds or ambers,
whatever the case may be.
25
COL STREIT: When you say “it’s stored in a folder”, does that mean, at
least as you understand it, there will be records at 6 Aviation Regiment for
aircrew completion of that tool?

30 D129: Correct. There’s currently – the policy is that they are all stored on
Objective for both aircrew, GCMS – or Ground Crew Mission Support –
personnel, and refuelling personnel – anyone involved in Aviation-related
duties.

35 COL STREIT: Do you consider the Fatigue Risk Awareness Tool, and the
way it’s now utilised within your unit, as something that has improved
Aviation safety?

D129: It has on occasion, yes.

40
COL STREIT: Have you ever had the experience, since you started using
the tool, of falling into the amber category of “Actively Manage”?

D129: Yes, I have fallen in the amber category.

45

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 COL STREIT: What about falling into the red category of “Caution”?

D129: I personally haven’t, no.

5 COL STREIT: Have you seen it occur though in relation to other aircrew
that you were identified to fly with on a particular day?

D129: Not that I’ve been flying with on a particular day, no.

10 MS McMURDO: So since this came in, how many flights would you have
done, roughly? Just a ballpark figure.

D129: Somewhere between 50 and 100, ma’am.

15 MS McMURDO: Thank you. Have other people identified as amber on

your flights?

D129: Yes, ma’am.

20 MS McMURDO: How do you manage that?

D129: So I haven’t had any ambers on the flights that I’ve been the Captain
of. Other sorties, it’s acknowledged and it sort of depends on the context
of the mission, the scores of the other crew, as to how that’s managed.
25
MS McMURDO: Have there been any significant changes to flights, flight
missions, because of someone being amber?

D129: I haven’t observed that, no.

30
MS McMURDO: You’re not aware of it. You said I think you, yourself,
had been in the amber on a couple of occasions.

D129: Yes, ma’am.

35
MS McMURDO: How did you manage that?

D129: I identified it and then, I guess, we continued flying.

40 MS McMURDO: Thank you.

COL STREIT: You may not have experienced this, but has there been any
discussion where you were present sort of around the crew – in the Crew
Room where other pilots have discussed whether they considered the
45 Fatigue Risk Awareness Tool was a useful tool or not a useful tool?

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 D129: I have. I think the consensus is that it’s useful in requiring people
to talk about fatigue prior to a sortie; whereas previously there was no strict
requirement to do so. However, at the moment there is some concern about
5 the additional administrative burden prior to commencing a sortie to carry
out this. You know, the need to log on, complete the tool, sign it, store it,
that sort of thing. But it’s been useful in requiring people to talk about
fatigue, at least.

10 COL STREIT: What about the process of just the aircrew of a particular
aircraft getting together in a group, completing the tool and then just
handing the tool to the Authorising Officer – a hard copy? Somebody else
can throw it on Objective.

15 D129: There’s probably no one else to put it on Objective. Yes, I’m not
sure who we would hand that job off to.

COL STREIT: So if there was some administrative support that didn’t

impact Aviation Operations, but just some administrative person who could
20 just take the hard copies and put them on Objective, then what I’ve
identified as a means of completion of the tool would release the admin
burden, wouldn’t it?

D129: It would reduce the burden a little bit, yes, sir.

25
COL STREIT: Might also assist in – it’s a bit different when you complete
the tool yourself as against doing it in a group where you have to eyeball
your fellow aircrewman and be honest about what you’re saying.

30 D129: Yes.

COL STREIT: Do you agree with that?

D129: I would agree with that. However, during formation sorties, in the
35 formation orders there is an indication provided across the crews as to how
many ambers that you may have. So it is known across the formation if a
particular aircraft has a certain number of ambers in it.

COL STREIT: Can I turn now to paragraph 14 and onwards? Now, I’m
40 going to read - - -

MS McMURDO: Just before you do that.

COL STREIT: Yes.

45

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 MS McMURDO: If you look at the “Actively Manage Fatigue and
Alertness” in the amber, one of the things it says there is to:

Consider taking a break or accessing controlled rest/napping.

5 Consider strategic use of caffeine and fluid intake.

Did you have any training about that?

D129: No, ma’am.

10
MS McMURDO: Thank you.

COL STREIT: If Exhibit 37 could be returned and the screen returned to

its normal function, please? I’m going to turn to paragraph 14 and onwards.
15 I’m just going to read aspects of this, D129, and I’ll just ask you to confirm
or otherwise what I’ve said. At paragraph 14 you say you first met Danniel
– that’s CAPT Lyon – in 2018, during your march in process to A Squadron,
5 Avn. It was a brief period as you believed he had not long returned from
his exchange with the Royal New Zealand Air Force and was completing
20 his march in/march out from 5 Avn, prior to posting to 6 Avn Regiment. Is
that correct?

D129: Yes, that’s my recollection.

25 COL STREIT: You then met him again in 2021 when you posted to
171 SOAS, 6 Squadron at 6 Aviation Regiment where he was the Squadron
Executive at the time. You say during your time at 6 Avn you became good
friends with Danniel and had a significant amount of respect for him as a
person, a professional and an aviator. You flew with Danniel on
30 approximately 10 occasions. You say he was a highly competent pilot, with
great passion for Aviation, and this was evident on each occasion that you
flew with him.

You say:
35
He became a Troop Commander in 2023 and, while the workload
was high, his absolute priority was performing highly to ensure the
members of his Troop were developed and had high morale and
felt valued members of the team.
40
Is that right?

D129: That’s correct.

45 COL STREIT:

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 He had a strong people-focused nature to his command, with a
significant amount of emotional intelligence. He was a
Commander that was respected, admired and trusted.
5
Is that right?

D129: That’s correct.

10 COL STREIT: Turning to Max Nugent. You say you met Max after he
posted to 6 Aviation Regiment in passing one of the Troop offices in about
June 2023, after you’d returned from overseas. He attended an SOQC
graduation ceremony – sorry, you attended an SOQC graduation ceremony
and the subsequent social function. Unfortunately, you did not get much
15 time to get to know Max better. You did not fly with Max on any occasion.
Is that right?

D129: That’s correct.

20 COL STREIT: In relation to WO2 Laycock you say you first met Phil
Laycock when he was posted back to 6 Aviation Regiment in 2022. You
worked with him in the Standards Cell as the Technical Adjutant in 2023.
You flew with Phil on approximately 30 or so occasions and he was an
excellent aircrewman. He was calm, deliberate and consistently had high
25 levels of situational awareness. You recall always feeling comfortable and
confident knowing you had Phil in the back of the aircraft.

You say Phil often provided both technical and general advice to you in
your role as the Regiment S35 Technical Adjutant, and as a pilot, in his
30 capacity as the Regiment Standards Warrant Officer and an experienced
aircrewman. You found his advice to be always well considered, relevant
and helpful. He was widely respected across the unit as the Regiment
Standards Warrant Officer and performed his duties to the highest standard.
Is that correct?
35
D129: That’s correct.

COL STREIT: In relation to CPL Naggs, you first met Alex on your
posting to 6 Aviation Regiment in 2021. You say Alex was quiet but a
40 competent and motivated aircrewman. You flew with him on approximately
20 occasions and always found him to be well prepared and a strong
performing member of the crew. Is that correct?

D129: That’s correct.

45

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 COL STREIT: Could I now turn to the Regimental Officers’ Intermediate
Course which you attended in 2022, which commences at paragraph 18 of
your statement. So at that time you were posted to 6 Aviation Regiment as
the Regiment S35 in 2022?
5
D129: That’s correct.

COL STREIT: You were also a Special Operations co-pilot on MRH-90.

10 D129: Correct.

COL STREIT: Now, the Regimental Officers’ Intermediate Course you

attended was conducted at Gallipoli Barracks and Oakey in 2022?

15 D129: Correct.

COL STREIT: On that course was the following persons, you say:
CAPT Lyon?

20 D129: Correct.

COL STREIT: D15?

D129: Correct.
25
COL STREIT: D55?

D129: Correct.

30 COL STREIT: CAPT Campbell Rogan?

D129: Correct.

COL STREIT: CAPT Matthew Goodridge?

35
D129: Correct.

COL STREIT: CAPT Ben Jackson?

40 D129: Correct.

COL STREIT: Paragraph 21 you say you were present at a number of

sections during the Regimental Officers’ Intermediate Course in which you
were given the opportunity to engage in conversations with senior Aviation
45 Officers across the Brigade and Command level with respect to

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 organisational concerns. Is that right?

D129: That’s correct.

5 COL STREIT: And can I just pause there. Is that your experience of
previous Aviation courses that you’ve attended, that there be an opportunity
to basically sit down and for the pilots at the coalface to express concerns
to chain of command? Or is this the first experience you’ve had?

10 D129: It’s probably the first experience I’ve had in that specific setting.
The ROIC is a course you do earlier in you career as a Captain, and it’s one
of the first Aviation-specific career courses you do post your graduation
onto Operation-type.

15 COL STREIT: So can I take it from that, given that it’s your first
experience, you would’ve been – because it’s new – fairly – you would’ve
been paying attention to what was going on in those discussions?

D129: Yes. Yes, I was.

20
COL STREIT: Now, you say that you recall the following senior officers
being present: BRIG Dean Thompson, then the 16 Aviation Brigade
Commander?

25 D129: Correct.

COL STREIT: COL Kim Gilfillan, then the Director Operational Air
Worthiness?

30 D129: Correct.

COL STREIT: COL David Lynch, then the Commandant of the Aviation
Training Centre?

35 D129: Correct.

COL STREIT: LTCOL Vanessa Jordan, the SO1 psychologist Aviation

Command?

40 D129: Correct.

COL STREIT: And LTCOL James Pidgeon, the S3 of 16 Aviation

Brigade?

45 D129: Correct.

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 COL STREIT: You say there were a number of sessions held and that the
majority were at Enoggera Barracks in Brisbane between 8 and 12 August
2022.
5
D129: Correct.

COL STREIT: When you say “Enoggera Barracks”, do you mean

Gallipoli Barracks?
10
D129: Yes, I do.

COL STREIT: Now, you say you can’t recall which days “we spoke to
senior officers”. Does that mean, paragraph 22 onwards, is that an
15 aggregation of your recollection of different conversations with senior
officers?

D129: Yes, that’s correct.

20 COL STREIT: Turning to paragraph 22, you say the peak concerns you
recall CAPT Lyon raising were predominately around workload tempo,
understaffing and fatigue.

D129: That’s correct.

25
COL STREIT: What was your observation of the manner in which he
conveyed his concerns?

D129: He conveyed them honestly and directly but in a respectful manner,

30 as was always the case. He was very passionate about the topic because he
and his colleagues were living and breathing those issues on a day to day,
and that’s the manner that he presented it in.

COL STREIT: Do you recall yourself saying anything in any of these

35 discussions?

D129: Yes, I did.

COL STREIT: And what did you say?

40
D129: They were very similar to the things that CAPT Lyon sort of
outlined and that I’ve outlined in my witness statement. It was
predominately around high tempo pilots conducting duties not related to
flying that was increasing the level of work they had to do and reducing
45 their ability to prepare, both mentally and physically, for flying but also in

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 maintaining the high level of technical knowledge required to be a pilot that
would often – you wouldn’t have sufficient time to maintain that level of
knowledge while also completing other duties.

5 COL STREIT: Now, at that point in time, you had some experience in
this, did you, because you’d undertaken other duties whilst trying to
maintain currencies in MRH-90 pilots?

D129: That’s correct.

10
COL STREIT: Did that include command duties?

D129: At the time I was the S35. So, yes, the Troop Commander of the
Crash Response Troop as well as being S35.
15
COL STREIT: So in the body of paragraph 22 you say:

CAPT Lyon outlined how pilots often had little to no time to

appropriately plan and prepare themselves prior to going flying as
20 they were often spending the majority of their time conducting the
duties of their primary role on the ground in positions such as
Troop Commander, XO or OPSO.

Is that right?
25
D129: That’s correct.

COL STREIT:

30 He also outlined how the high levels of knowledge about Aviation

policy and procedures during training and the first year or two in
an order degraded rapidly once placed in a high workload
command or operations position as there was simply not enough
time to complete that duty, fly regularly and allocate time to
35 maintain a recallable level of knowledge about policy and
procedures.

D129: That’s correct.

40 COL STREIT: Do you agree with him?

D129: Yes, I did.

COL STREIT: You say he went on further to say:

45

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 These factors, coupled with notable understaffing, would then in
turn lead to sustained high levels of fatigue among personnel in key
positions. They often needed to work long hours in order to meet
all the requirements placed on them.
5
D129: That’s correct.

COL STREIT: You recall him saying those things.

10 D129: Yes.

COL STREIT: And did you agree with him on those things.

D129: I did.
15
COL STREIT: You say the response from officers was varied. You say:

BRIG Thompson acknowledged the concerns and provided

guidance that he wanted us to reduce, where possible, effort on
20 aspects of our daily jobs that were not directly relevant or
contributory to the required outcome. He provided one example of
making an instruction of an activity on only two pages.

Do you recall him saying that?

25
D129: Yes, I do recall that specific example with respect to the
administration.

COL STREIT: It was your view though that that suggestion wasn’t simply
30 possible because it didn’t take into account the level of administration
required to plan and execute an Aviation activity.

D129: That’s correct.

35 COL STREIT: And that was something you were living with on a daily
basis at that time?

D129: Correct.

40 COL STREIT: You say most of the other officers you’ve identified in
your statement broadly acknowledged the concerns, but you can’t recall
specific details about their individual responses. Is that right?

D129: That’s correct.

45

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 COL STREIT: You then say this:

LTCOL Jordon –

5 now, that’s the Aviation psychologist – you say:

LTCOL Jordon, from my recollection, appeared to be most

concerned about the issues we were raising and offered her
support.
10
When you say she “appeared to be most concerned about the issues” that
were being raised, how did you form that view? Did she say something to
you?

15 D129: I think it was just in her response to us as a group talking about

these things. Yes, I think she recognised the sort of pressure that people
were under and how that might affect Aviation Operations.

COL STREIT: Now, if you cast your mind back to when you’re observing
20 her say these things to you and the group – is that right?

D129: Yes, that’s correct.

COL STREIT: Who else was present in terms of the senior officers at the
25 time?

D129: I can’t recall. I don’t think there were many. Those conversations
occurred as an adjunct to the presentation that she was giving at the time
about her role in the organisation. That was sort of part of the scheme of
30 events was each of the officers providing us a brief on what their role was,
what their job was.

COL STREIT: Can you remember whether this briefing that

LTCOL Jordan is saying these things to you, was that at Gallipoli Barracks
35 or at Oakey?

D129: That was at Gallipoli Barracks.

MS McMURDO: Her role was psychological support?

40
D129: Correct.

MS McMURDO: Welfare support.

45 D129: That’s right, ma’am.

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 MS McMURDO: The support that seemed to come from the more senior
officers was coming through her, and she was able to offer support and ways
of dealing with stress?
5
D129: Yes.

MS McMURDO: Rather than alleviating the problem that was causing it?

10 D129: That’s correct, ma’am. She was offering support in her role.

MS McMURDO: Yes.

COL STREIT: You then say this – last sentence of paragraph 22, you say:
15
Our session with DOP - - -

D129: DOPAW.

20 COL STREIT: DOPAW. Is that - - -

D129: Director Operational - - -

COL STREIT: Sorry. I’ll let you say it. You’re in Aviation - - -
25
D129: Director of Operational Airworthiness, sir.

COL STREIT: Thank you.

30 The Director of Operational Airworthiness, COL Gilfillan made

the remark that we were engaging in “diatribes” with respect to
the concerns that we were raising. He appeared to believe our
concerns were exaggerated and not reflective of the reality.

35 D129: That’s correct.

COL STREIT: Do you remember him using the word “diatribe”?

D129: I specifically remember that, yes.

40
COL STREIT: What did you take that to mean? Like, what did you
understand the word “diatribe” - - -

D129: To be honest, I actually had to look that word up after the event.
45 But given the context, I assumed it meant something to do with going on a

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 long sort of rant about a particular topic.

MS McMURDO: An unjustified rant, is that what you - - -

5 D129: Potentially, ma’am. Yes, from when I looked it up that many years
ago I think I recall that.

COL STREIT: I turn now to paragraph 23 of your statement, please.

Largely, paragraph 23 deals with matters – I think you’ve already given
10 some evidence about – or you indicate you agree with all of CAPT Lyon’s
concerns. You then say this about halfway down the paragraph, you say:

The current model in Army Aviation is that flying in a secondary

role pilots and aircrew to be completed around your other duties
15 within the unit and Army. These issues are amplified by a culture
of mission success at all costs, a culture that is pervasive across
the organisation even during foundation training.

Army Aviation units are consistently under pressure to support all

20 tasks and missions assigned to them despite not having required
levels of staffing capacity to achieve them, which usually results in
highly compressed timelines that force aircrew into situations in
which they are not prepared as they need to be, which in turn
greatly reduces safety margins.
25
They’re your views based on your experiences today?

D129: That’s correct.

30 COL STREIT: You then say further:

Should aircrew identify they’re not in a satisfactory position to

execute a task, then a delay may incur in order to allow sufficient
preparation. However, this delays timeline compression to any
35 follow-on tasks or missions and acts only to defer the issue to a
later period.

I take it from that you’re saying there’s a knock-on effect?

40 D129: Yes. We occasionally have buffers built into the program that, by
moving things to the right, delaying them, that ultimately means that your
next event or activity is further compressed.

COL STREIT: Is one way of summarising it, what you’ve said in

45 paragraph 23 is that at the coalface there’s a desire and a pressure to get the

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 job done?

D129: Correct.

5 COL STREIT: People at the coalface don’t want to let the team down.

D129: Correct.

COL STREIT: They don’t want to let the chain of command down.
10
D129: Correct.

COL STREIT: So they just push themselves to get the job done.

15 D129: Correct.

COL STREIT: I turn to paragraph 25 of your statement. There are certain

aspects of paragraph 25 I won’t lead because they deal with capability. And
I ask Counsel representing to be mindful of that, should they wish to ask
20 this witness any questions. But is the sum total of paragraph 25, in effect,
that your experiences are, to date – that is, during 2024 – in terms of
workload pressures and fatigue, it still exist today within the unit?

D129: That’s correct.

25
COL STREIT: Are you familiar with snapshot surveys?

D129: I am.

30 COL STREIT: And have you participated in snapshot surveys?

D129: Yes, I have.

COL STREIT: Can you just briefly explain what a snapshot survey is?
35
D129: It’s like a PULSE check survey that’s taken at a point in time;
usually sort of in the first half of the year. Its purpose is to provide
Commanders with an overview of different aspects of the organisation in
relation to how personnel safety is tracking. And there’s a whole bunch of
40 metrics and presentations that is generated as a result of the responses to
that survey.

COL STREIT: Do you recall receiving any briefings about the outcome
of snapshot surveys?
45

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 D129: I have in the past, yes.

COL STREIT: Do you recall when you received the last briefing?

5 D129: I think the last briefing I received would have been in 2022 while
we were away on an exercise. And from memory that was the last one.

COL STREIT: Since you’ve been a pilot, have snapshot surveys been an
annual event you’ve engaged in?
10
D129: Yes, every year.

COL STREIT: Would you receive briefs from the chain of command
about the outcomes of those snapshot surveys?
15
D129: That’s usually the case, yes.

COL STREIT: And to your recollection were there any recurring themes
in terms of those snapshot surveys?
20
D129: Yes. Yes.

COL STREIT: What were they?

25 D129: Usually, it was fatigue and tempo were the predominate factors in
which the data points were, you know, quite obvious.

COL STREIT: Are you aware of a KMPG town hall being conducted in
recent times – the last couple of years or so, where pilots were engaged?
30 Does that ring a bell for you at all?

D129: I’ve heard of townhalls but not specifically KPMG-run town halls,
no.

35 COL STREIT: Thank you, D129. Ms McMurdo, they’re my questions.

MS McMURDO: Thank you. Can I just ask a couple of things? You

mentioned that you were a Group Captain when you were a third year
Captain, which is relatively inexperienced. We have heard from others that
40 it’s not until a year seven that Captains are paid for being a Troop
Commander.

D129: That’s right, ma’am. Yes, Captain 7 is when that takes effect.

45 MS McMURDO: Did you feel that that you were still on too much of a

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 learning curve and still learning the role to become a Troop Commander at
that stage?

D129: I guess my particular Troop Commander was of a capability that I

5 didn’t have much knowledge, yes.

MS McMURDO: Thank you. If I could take you to paragraph 6(c) on

page 3 of your statement? You mention there when you were focused on
identifying capability requirements at unit level and developing plans to
10 mitigate capability gaps and enhance existing capability, your focus was in
the final coordination and implementation of the 6th Aviation Regiment
sleep study. Could you tell us a little bit about that?

D129: Yes, ma’am. So the sleep study was an initiative of the CO at the
15 time. He wanted to gain more information – more objective information, I
should say, about how exercises and different tempo periods affected
personnel’s sleep quality and quantity to better inform his fatigue
management practices.

20 MS McMURDO: And this is in the first half of 2023?

D129: That’s correct, ma’am.

MS McMURDO: And who was the CO at that time?

25
D129: I’ll just have to refer to the lists. D19.

MS McMURDO: D19. And do you recall any results of that sleep study,
or what it showed in general, or anything about it?
30
D129: The sleep study did not end up going ahead.

MS McMURDO: Not go ahead, okay. Right. Yes, thank you.

35 Did you have any questions? No. Any questions? No. Any applications
to cross-examine? No applications to cross-examine.

Could I thank you very much for coming forward, for your courage and
leadership. Other members of the ADF have shown like courage and
40 leadership. And can I say that such courage, leadership and honesty is
absolutely in the best interests of the Australian Defence Force.

D129: Thank you, ma’am.

45 MS McMURDO: Thank you. Yes, you’re excused and free to go.

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 D129: Thank you, ma’am.

5 <WITNESS WITHDREW

MS McMURDO: I suppose it’s lunchtime. Did you want to call – yes,

another witness in first?
10
COL STREIT: I’m just going to see if the next witness is waiting outside.

MS McMURDO: All right then. Won’t be long?

15 COL STREIT: Perhaps if I could make a - - -

MS McMURDO: Okay, you let me know then when you wish to - - -

COL STREIT: Yes.

20
MS McMURDO: All right then.

COL STREIT: I call GPCAPT Christopher Pouncey, please.

Ms McMurdo, the camera can now return to displaying video.
25
MS McMURDO: Thank you.

CLERK OF THE COURT: Do you choose to take the oath or affirmation?

30 GPCAPT POUNCEY: Affirmation, please.

<GPCAPT CHRISTOPHER POUNCEY, Affirmed

35
<EXAMINATION-IN-CHIEF BY COL STREIT

COL STREIT: Group Captain, we’ll make a start with your evidence and
40 then we’ll shortly adjourn for the lunch break, and conclude your evidence
immediately following lunch. Can I just begin by asking you to state your
full name and rank?

GPCAPT POUNCEY: GPCAPT Chris Pouncey.

45

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 COL STREIT: And what is your current role?

GPAPT POUNCEY: I’m the Director of Aviation Operations in the

Defence Aviation Safety Authority.
5
COL STREIT: Now, please feel free to pour yourself a glass of water if
you wish. Can I ask you just some preliminary matters? Did you receive a
section 23 Notice to appear here today?

10 GPCAPT POUNCEY: Yes.

COL STREIT: And did you also receive a Frequently Asked Guide For
Witnesses?

15 GPCAPT POUNCEY: Yes.

COL STREIT: A Privacy Notice?

GPCAPT POUNCEY: Yes.

20
COL STREIT: An extract of the Inquiry’s Directions?

GPCAPT POUNCEY: Yes.

25 COL STREIT: And in terms of the section 23 Notice, did that contain
some questions which then asked you to generate a statement?

GPCAPT POUNCEY: Yes.

30 COL STREIT: What I’m going to do now is provide you a document. I’ll
just ask you to examine the document and I’ll ask some further questions.
Can I just confirm, is that document your statement?

GPCAPT POUNCEY: Yes.

35
COL STREIT: And is it digitally signed by you on 14 June 2024?

GPCAPT POUNCEY: Yes.

40 COL STREIT: Are there any amendments you wish to make to your
statement?

GPCAPT POUNCEY: Yes, just one minor editorial in the reference list.

45 COL STREIT: Yes.

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 GPCAPT POUNCEY: At reference India, where it says “of 12 December
‘23”, it should read “of 12 December ‘22”.

5 COL STREIT: Thank you. Could you make that annotation on your
witness statement and just initial where you have made that change, thank
you. Ms McMurdo, I tender the statement of GPCAPT Pouncey of
14 June 2024.

10 MS McMURDO: That’ll be Exhibit 47. Thank you.

#EXHIBIT 47 - STATEMENT OF GPCAPT POUNCEY

DATED 14/06/24
15

COL STREIT: Now, Group Captain, can I just – no doubt you’re across
this, but can I just remind you to be mindful of your security obligations. If
I ask a question, or Counsel Assisting or anyone asks you a question for that
20 matter, where you consider responding to that question would mean going
into a security classification that’s higher than “Official”, could you just
alert us to that matter. We can only deal with those issues in a private
hearing.

25 GPCAPT POUNCEY: Understood.

COL STREIT: Thank you. Now, can I just ask you to go to paragraph 4
of your statement. What I propose to do is to lead you through aspects of
your statement; that is, my reading certain things and asking you to confirm
30 if I’ve accurately read out what you have said. And in other aspects of your
statement, I’ll ask you to explain certain things by way of giving evidence.

So your background is an Officer in Aviation. You’re a fixed-wing pilot?

35 GPCAPT POUNCEY: Yes.

COL STREIT: You’ve served in the Air Force for over 30 years and you
have over 5000 hours of military flying experience?

40 GPCAPT POUNCEY: Yes.

COL STREIT: You’ve flown a range of different aircraft, including the

PC-21, the Tucano – is that how you pronounce it?

45 GPCAPT POUNCEY: Tucano.

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 COL STREIT: Tucano; the CT/4B, the Cariboo; and the PC-9A,
including as a Roulette.

5 GPCAPT POUNCEY: Yes.

COL STREIT: So for those who don’t know, what’s a Roulette?

GPCAPT POUNCEY: That’s a member of the Royal Australian Air

10 Force’s formation aerobatics display team.

COL STREIT: And do you recall how long you performed that role for?

GPCAPT POUNCEY: I performed the role for one season in 2009,

15 approximately six months.

COL STREIT: And perhaps to state the obvious, needing to be a Roulette

and flying as a Roulette requires a level of significant precision flying.
Would that be correct?
20
GPCAPT POUNCEY: Yes.

COL STREIT: You have 82.8 hours flying on night-vision imaging

systems?
25
GPCAPT POUNCEY: That’s correct.

COL STREIT: Do you recall what that night-vision imaging system was?
Was it, for example – it wasn’t TopOwl, was it?
30
GPCAPT POUNCEY: It was not TopOwl, no.

COL STREIT: You’ve instructed at all of the ADF’s fixed-wing flying

schools, including as a Chief Flying Instructor of the 2nd Flight Training
35 School. Is that correct?

GPCAPT POUNCEY: Yes.

COL STREIT: And you’ve been Commanding Officer of the 1st Flight
40 Training School.

GPCAPT POUNCEY: Number 1 Flying Training School, yes.

COL STREIT: Number 1.

45

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 GPCAPT POUNCEY: Yes.

COL STREIT: Thank you. You’ve served on warlike operations in then

East Timor and non-warlike operations in the Middle East.
5
GPCAPT POUNCEY: That’s correct.

COL STREIT: You’ve held qualifications as a B CAT Aircraft Captain

and Qualified Flying Instructor?
10
GPCAPT POUNCEY: Yes.

COL STREIT: You also have held qualifications as a senior Instrument

Rating Examiner. I’ll just pause there. Just explain what that role is?
15
GPCAPT POUNCEY: So perhaps it will be easiest to start with an
explanation of what an Instrument Rating Examiner is.

COL STREIT: Sure.

20
GPCAPT POUNCEY: And then to the role of a senior Instrument Rating
Examiner. So all Defence Aviation pilots are required to participate in a
PIRS, or Pilots’ Instrument Rating Scheme. The function of the Pilots’
Instrument Rating Scheme is to ensure that pilots have the necessary skills,
25 knowledge and attitudes to operate aircraft safely in IMC or Instrument
Meteorological Conditions.

An Instrument Rating Examiner is a pilot who has been awarded the

qualification of Instrument Rating Examiner which qualifies them to
30 conduct instrument rating tests for participants in the Pilot Instrument
Rating Scheme; that is, other pilots. A senior Instrument Rating Examiner
is typically a Qualified Flying Instructor who has also held an IRE
qualification, who’s responsible for conducting the assessments on
Instrument Rating Examiners to ensure that they have the knowledge, skills
35 and attitudes required to perform their Instrument Rating Examiner duties
effectively.

COL STREIT: Thank you. You’ve also been a Unit Maintenance Test
Pilot. And which aircraft – or was that multiple aircrafts?
40
GPCAPT POUNCEY: On the PC-9A.

COL STREIT: Thank you. You graduated from the Australian Command
and Staff College, and the Australian Defence Force Academy. You hold
45 a Masters degree in Military and Defence Studies, and Bachelor degrees of

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 Technology and Aeronautical Engineering. Correct?

GPCAPT POUNCEY: Yes.

5 COL STREIT: Now, can you just broadly explain your current role?

GPCAPT POUNCEY: So my current role is the Director of Aviation

Operations and Defence Aviation Safety Authority, colloquially – or
abbreviated to DAVN Ops. DAVN Ops is responsible for safety assurance
10 functions 1 to 4 of a number of regulated entities typically of an operational
nature, including Military Air Operators. And Aviation Command is a
Military Air Operator.

COL STREIT: Can you just say – it might be obvious to you, but not
15 necessarily others, but what is the Defence Aviation Safety Regulation?

GPCAPT POUNCEY: So the Defence Aviation Safety Regulations are a

set of policy. They are part of the Defence Aviation Safety Program. The
Defence Aviation Safety Program is established by the Joint Directive of
20 the Secretary and CDF 21/2021. It’s described in the Defence Aviation
Safety Program Manual and, perhaps in plain English, the Defence Aviation
Safety Regulations provide policy, explain Defence’s WHS Act 2011 (Cth)
obligations in the Defence Aviation environment.

25 COL STREIT: Now, at the bottom of paragraph 8 you say this:

Specifically in respect of Command, such as Aviation Command,

reference A –

30 I pause there. Reference A is the Joint Directive 21/2021 by the Secretary

and the Chief of the Defence Force, the Defence Aviation Safety
Framework of 10 November ‘21. I continue –

specifies, “Aviation safety is a Command responsibility. While this

35 Directive establishes a framework for the management of Aviation
safety within Defence, responsibility for ensuring the safe
operation of Aviation systems rests with the command chain.
Commanders and managers are, therefore, accountable to
ensuring Aviation systems under their command or control are
40 designed, constructed, maintained and operated to approved
standards and limitations by competent and authorised personnel
acting as members of an approved organisation.

So that’s what is incumbent on Commanders. How does the Defence

45 Aviation Safety Regulation assist them in achieving what CDF and the

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 Secretary have asked?

GPCAPT POUNCEY: I just pause for a moment and refer to my notes and
consider your question. So the Defence Aviation Safety Regulations assist
5 Command in meeting the obligations that you’ve just described outlined in
the Joint Directive of 21/2021 by providing those Commanders with a raft
of regulatory passive controls compliance which will support them in
putting in place safety controls against those hazards in Defence Aviation.

10 COL STREIT: Thank you. Ms McMurdo, I note the time. It might be

appropriate for the luncheon adjournment.

MS McMURDO: Thank you very much. I know you’ve been waiting

patiently, we still haven’t finished with you but we’ll have an adjournment
15 for lunch now and resume at 1 o’clock.

COL STREIT: 1 o’clock.

MS McMURDO: Yes.
20
GPCAPT POUNCEY: Yes, ma’am.

HEARING ADJOURNED
25

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 HEARING RESUMED

MS McMURDO: Yes, COL Streit.

5
COL STREIT: Thank you, Ms McMurdo.

Group Captain, can I just take you to paragraph 7 – or more particularly the
heading, “Implementation and Compliance”, and the proceeding – or the
10 paragraphs that are after that. Can you just explain in broad terms how a
Defence Aviation Safety Regulation may be amended, the process?

GPCAPT POUNCEY: So the process that directs DASA staff in terms of

the methodology for updating a Defence Aviation Safety Regulation is one
15 of the references to my submission. It is reference D, DASA Instruction
Reg 1-2, DASR Amendment Management.

COL STREIT: Paragraph 12 perhaps might assist you as well in

responding to this question.
20
GPCAPT POUNCEY: Thank you. In summary, the key artefacts and
activities in that process include a concept endorsement decision brief for
DGDASA, a Notice Proposing Amendment and an associated news break
which advise the regulator community – in this case, including Aviation
25 Command – of DASA’s intention to publish a new or updated regulation,
including a draft of that regulation and inviting comments.

It also includes a Comment Response document, subsequent to the Notice

Proposing Amendment, which document the comments from the regulator
30 community and DASA’s response to those comments, including any
subsequent amendments to the proposed regulation. It also includes a
Regulation Impact Statement outlining the expected impacts of the new or
updated regulation for Defence Aviation Safety Board endorsement; and,
finally, an approval decision brief for DGDASA.
35
COL STREIT: In your experience – and I’m not asking for a precision
response here; I appreciate that may not be achievable – but in your
experience, approximate timelines from concept or considering an
amendment to a regulation to the regulation being amended and published
40 – is there, in your experience, an approximate timeline that occurs?

GPCAPT POUNCEY: Yes, certainly. So for this type of update to a

regulation, which I would describe as a major update, that would take a
minimum of nine months and could take up to 18 months from concept
45 development to publication.

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 COL STREIT: From concept development to publication, that period of
time, whether it’s nine months or 18 months, or anything in between,
involves engagement with relevant stakeholders so they can provide input
5 into what’s proposed?

GPCAPT POUNCEY: That’s correct.

COL STREIT: That would include Aviation Command, for example, if it

10 was relevant to their interests?

GPCAPT POUNCEY: That’s correct.

COL STREIT: So a Command – if we think more broadly, the three

15 Services – a Command would have knowledge that a change was being
proposed; correct?

GPCAPT POUNCEY: Yes.

20 COL STREIT: And the ability to provide input into that change?

GPCAPT POUNCEY: Yes.

COL STREIT: So when the change occurred, in whatever manifestation,

25 it would not come as a surprise to that Command?

GPCAPT POUNCEY: That’s true.

COL STREIT: So in one sense, a Command that might be a little bit ahead
30 of its time, anticipating that a change to the regulation is coming into effect,
could already start their own internal appreciation processes about how they
would give effect to that change within their own policies?

GPCAPT POUNCEY: That’s true. I would add the qualification that

35 that’s not a requirement of the DASP and that the DASP has associated
transition periods which follow publication to provide the regulator
community time to put in place the necessary amendments to their system
to comply with that new regulation.

40 COL STREIT: Now, in terms of those periods you just described – that is,
the period from when the regulation comes into existence and the period
before the regulation becomes enforceable; that is, that period of time to
allow Commands to transition whatever policies they have – how is that
period of time determined?
45

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 GPCAPT POUNCEY: So DASA nominates a period of time, typically
12 months. In the case, for example, of DASR SPA.55 Night-Vision
Imaging Systems, we shortened that transition period to nine months. Part
of the rationale for shortening that transition period to nine months was that
5 there was a change to the cycle or the battle rhythm of DASA publications.
Previously, updates were published in April and October of each year. We
were moving to a February and July publication routine.

This regulation would otherwise have been published in the October 2022
10 but because of the change in cycle, it moved to February 2023. But in order
that we didn’t further delay the transition, the transition period was
shortened from a typical transition period of 12 months to nine months, to
also end in October 2023.

15 COL STREIT: Now, have you ever experienced a circumstance where a

regulation is changed as a consequence of a safety issue that’s been
identified?

GPCAPT POUNCEY: So all of our updates, major updates to regulation,

20 are informed by safety intelligence and that safety intelligence includes
significant Aviation safety events, both within Defence Aviation and also
in global aviation.

COL STREIT: Let’s now turn to - - -

25
MS McMURDO: Could I just ask you if, for example – and I know this
wasn’t such a one – but if, for example, an amendment was needed because
of urgent safety reasons, is there capacity to speed it up below the
nine months in those situations?
30
GPCAPT POUNCEY: It’s not beyond possible. In my tenure, I’ve not
seen a transition period for a major update to a regulation in shorter than
nine months, ma’am.

35 MS McMURDO: But then would that also be because you haven’t seen
one where it was an emergency situation, or some safety issue had to be
urgently fixed?

GPCAPT POUNCEY: So there are other mechanisms that DASA has to

40 deal with safety issues that have greater temporal pressure, ma’am.

MS McMURDO: Thank you.

COL STREIT: Can I take you to paragraph 14 of your statement, please?

45 I apologise, we’ll start at 13. I just want to now ask you some questions in

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 relation to the Regulation SPA.55 NVIS which came into effect – well,
which was published on 23 February 2023. Is that right?

GPCAPT POUNCEY: That’s correct.

5
COL STREIT: Now, first, what led to the amendment to the regulation in
that matter?

GPCAPT POUNCEY: So there were a number of inputs to our scoping

10 activity which led to that major update, including a review of safety
intelligence, a benchmarking activity against exemplar Military Aviation
Authorities, or MAAs, and Civil Aviation Authorities, or CAA regulation
sets. There was also some hazard analysis and a review of the legacy
Defence Aviation Regulations.
15
COL STREIT: Was one of the catalysts for change - if you refer to
paragraph 13(a), you say:

A review of safety intelligence (including references K and L).

20
Was one of the catalysts for change, reference K of your statement, which
is a reference to a Defence Flight Safety Bureau Aviation Safety
Investigation Report, MRH-90 formation near collision, Townsville, FTA
of 11 November 2020.
25
GPCAPT POUNCEY: Yes.

COL STREIT: Can you just explain in broad terms what your
understanding was of the outcome of that investigation?
30
GPCAPT POUNCEY: So one of the key outcomes of that investigation
that informed the update to DASR SPA.55 was that that investigation
centred on an event in which an MRH-90 aircraft, operating within an
MRH-90 element of a larger formation of dissimilar aircraft, experienced a
35 situation where that aircraft’s crew went blind on the preceding aircraft in
that MRH-90 formation and, in the subsequent events that followed, passed
in close proximity without situational awareness of that preceding aircraft
in the formation.

40 One of the contributing factors to that sequence of events was that at the
time AVNCOMD had not prescribed minimum illumination levels for
certain – or for any NVIS operations. And so it was a result of that element
of safety intelligence that we considered including a regulatory hazard
control requiring Military Air Operators to promulgate minimum
45 illumination levels for certain NVIS operations.

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 COL STREIT: Thank you. So an MRH-90 flying at night in formation;
correct?

5 GPCAPT POUNCEY: Yes.

COL STREIT: Nearly collided with another aircraft?

GPCAPT POUNCEY: Yes.

10
COL STREIT: As a consequence of losing situational awareness of where
that aircraft was?

GPCAPT POUNCEY: Yes.

15
COL STREIT: And one of the factors identified – was it as a causal factor
concerning matters relating to low illumination?

GPCAPT POUNCEY: Yes.

20
COL STREIT: And that was one of the causal factors driving the change
to the DASA regulation concerning night-vision imagery devices?

GPCAPT POUNCEY: It was certainly a safety intelligence input that we

25 used to inform the drafting of the new regulation, yes.

COL STREIT: Also, there was, if I understood your evidence correctly,

no Avn Command policy dealing with the conduct of operations in that
level of low illumination?
30
GPCAPT POUNCEY: AVNCOMD had not, at the time, prescribed
minimum illumination levels for NVIS operations.

AVM HARLAND: Were they required to, beforehand, under a regulatory

35 guidance?

GPCAPT POUNCEY: They were not, sir.

AVM HARLAND: A question just regarding that. So when was the

40 Notice of Proposed Amendment for DASR SPA.55 NVIS put out?

GPCAPT POUNCEY: Just bear with me a second. I’ll refer to my notes,

sir. So DASA issued the Newsbreak advertising the notice proposing
amendment for DASR SPA.55 on 16 June 2022, sir.
45

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 AVM HARLAND: So at that stage it would be fair to say that the Aviation
community, including Aviation Command, were aware of the intention to
publish a new regulation, and would have been given a draft of that
regulation, according to para 12(b)?
5
GPCAPT POUNCEY: Yes, that’s correct, sir.

AVM HARLAND: Okay. That’s all I have for now.

10 COL STREIT: Thank you.

Just for clarification, when you say you just need to refer to your notes, in
case Counsel representing start wondering if I’ve disclosed to them notes
that you have, you’re actually referring to your statement, aren’t you?
15
GPCAPT POUNCEY: Yes, that is correct. I’m referring to the statement.
I do not have separate notes.

COL STREIT: Thank you.

20
AVM HARLAND: In fact – sorry, COL Streit – when did work begin on
the draft regulation for DASR SPA.55?

GPCAPT POUNCEY: Give me a moment, sir, and I’ll refer to my

25 statement. Work would have begun on DASR SPA.55 in DASA in the
weeks leading up to 22 May ‘22, sir.

AVM HARLAND: Thank you.

30 COL STREIT: At paragraph 14 you say this:

DASA communicated the expectation of timing implemented by

DASR SPA.55 in reference H as follows:

35 “DASA incorporated a transition plan with the update

to DASR SPA.55. In this plan, DASA will provide a
nine-month transition period commencing on date of
publication of DASR SPA.55 (23 Feb ’23). This
transition period will allow the regulated community to
40 make the necessary changes to their management
systems. DASA will not enforce compliance with
DASR SPA.55 when conducting oversight activity
during the transition period. DASA will consider
extensions to the transition period on request.”
45

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 What I’ve just read out, is that correct?

GPCAPT POUNCEY: Yes.

5 COL STREIT: Just to break that down perhaps. So DASA recognised a

need to amend DASR SPA.55 as a result of matters that you’ve addressed
in paragraph 13 of your statement?

GPCAPT POUNCEY: Yes.

10
COL STREIT: So, in essence, the amendment to DASR SPA.55 is a – to
state the obvious, it’s an amendment for safety purposes, isn’t it?

GPCAPT POUNCEY: Yes.

15
COL STREIT: One of the inputs as to why the amendment was necessary
was because Aviation Command were conducting operations in low
illumination without a policy dealing with that matter, which was one of the
causal factors of the near miss in 2020 between an MRH-90 aircraft and
20 another aircraft.

GPCAPT POUNCEY: Certainly it was a recommendation from the report,

listed at reference K, that AVNCOMD should consider implementing such
policy, yes.
25
COL STREIT: But DASA took its own action in relation to the matter and
commenced an amendment of the DASR SPA.55 regulation; is that right?

GPCAPT POUNCEY: Yes.

30
COL STREIT: So what I want to ask is this. Given that DASA had
identified there was a need to amend the regulation for a safety purpose –
that there’d been a near miss of an MRH-90 with another aircraft at night
in low illumination, which was an input to cause the amendment to the
35 regulation – the regulation commenced and would not have been any
surprise to Aviation Command, being a stakeholder and involved in the
process of formulation of the regulation, why then would Aviation
Command be permitted a nine-month window in which to bring in changes
to their own policies before the regulation took effect?
40
GPCAPT POUNCEY: I’ll just refer to my statement.

COL STREIT: Sure.

45

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 GPCAPT POUNCEY:

New or updated Defence Aviation Safety Regulations may

introduce new obligations on a Military Air - - -
5
MS McMURDO: Just tell us what paragraph you’re referring to, please?

GPCAPT POUNCEY: Paragraph 11(b), ma’am.

10 MS McMURDO: Thank you.

GPCAPT POUNCEY:

New or updated Defence Aviation Safety Regulations may

15 introduce new obligations on a Military Air Operator, such as
Aviation Command. These new obligations may require a change
to the Military Air Operator’s flying management system, quality
management system, safety management system, or other elements
of the Military Air Operator’s Organisation. To conceive of and
20 implement such changes requires a finite amount of time and
resources, including staff.

The staff necessary to implement such changes are often the same
staff required to perform other functions that the relevant
25 Command is obliged to perform. Accordingly, when DASA
introduces a new Defence Aviation Safety Regulation, or an
updated Defence Aviation Safety Regulation, DASA will publish a
transition period.

30 This transition period allows the Military Air Operator time to

implement the necessary changes to comply with the new or
updated Defence Aviation Safety Regulation, after the new or
updated Defence Aviation Safety Regulation is published, but
before DASA will require the Military Air Operator to comply with
35 the DASR.

COL STREIT: Why can’t DASA simply issue a regulation and say,
“Aviation operations are only permitted to this level of illumination from
this date”, and then let the Commands adjust their own processes and
40 missions, because all that’s changing is the conduct of a mission in a
particular illumination level, isn’t it?

GPCAPT POUNCEY: In effect, that’s exactly what we did. So the end of

the transition period was that date from which DASA required
45 Avn Command and all Military Air Operators to, amongst other things,

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 incorporate minimum illumination levels as part of their hazard controls –
the night-vision imaging system operations.

COL STREIT: Sure, I understand that, but what it means is that the
5 regulation comes into effect and then there’s a nine-month window where
Aviation Command, or another Command, can continue to conduct
operations in whatever illumination they want, which might be, if the
regulation was in effect, contrary to the regulation. The regulation doesn’t
have any teeth because it’s not in effect for nine months.
10
GPCAPT POUNCEY: That’s true.

COL STREIT: Perhaps if you can assist the Inquiry, what is the magic in
the 12 months or the nine months in allowing a transition in relation to this
15 change to the regulation, and why wasn’t it done earlier?

GPCAPT POUNCEY: Sir, there is no magic. I would describe the

12-month period as by convention, or based on historical experience of the
timeframe necessary to make considered and comprehensive changes to a
20 Military Air Operator’s flying management system, safety management
system, quality management system, and other elements of the Military Air
Operator’s Organisation.

MS McMURDO: Just following on from COL Streit’s suggestion then,

25 would it not be possible to still have that process to do the formal change to
the regulation but to at least send out a warning, “We have this concern.
We’re changing the regulation. For safety reasons, you should consider in
the interim”, dah, dah, dah, so there’s not flying in these low light
conditions? Is that something that - - -
30
GPCAPT POUNCEY: That’s not a documented part of the Defence
Aviation Safety Program, ma’am, and the challenge to making that such a
part of the Defence Aviation Safety Program would be that the change to
the regulation in respect to minimum illumination levels is just of numerous
35 changes to that regulation. The safety event that we referred to at
reference K was just one of a number of safety events which informed that
regulation to - - -

MS McMURDO: Well, there was K and L. Was there anything other than
40 K and L in terms of safety events?

GPCAPT POUNCEY: I would have to take that question on notice,

ma’am. Certainly K and L were notable safety events in the Defence
Aviation aviation safety history. But to conclude my point, Aviation
45 operations are a complicated activity, and to make a change to Aviation

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 operations effectively, and without having an adverse second order effect
on safety or capability, requires a finite amount of time to put in place
considered safety measures.

5 MS McMURDO: You mentioned, when I asked you about these questions

earlier, that you had other safety – for urgent safety concerns, there were
other processes.

GPCAPT POUNCEY: Yes, ma’am.

10
MS McMURDO: Can you just give us an outline of what they would be?

GPCAPT POUNCEY: So one example is an Airworthiness Directive. So

in an Airworthiness Directive, typically associated with an aircraft design
15 issue, the Defence Aviation Safety Authority may issue an Airworthiness
Directive, placing certain restrictions on an aircraft’s operation, and may
place a certain time limit associated with that.

I would emphasise that DAVN Ops is not responsible, typically, for

20 Airworthiness Directives, and further questions on Airworthiness
Directives would best be directed to AIRCDRE Joe Medved, DGDASA,
ma’am.

AVM HARLAND: In your experience as DAVN Ops, has there been an

25 Airworthiness Directive issued to address an operational issue rather than a
technical issue?

GPCAPT POUNCEY: Not as the primary means or the primary driving

factor for the issue of that Airworthiness Directive, no, sir. But as you
30 would be aware, sir, many – in Defence Aviation, particularly since the
Sea King Board of Inquiry, we take an integrated view of Defence Aviation
safety. So there are typically operational inputs into Airworthiness
Directives which have as their initial trigger design or other matters - - -

35 AVM HARLAND: I’m just trying to, I guess, understand. So the DASR
SPA.55 was introduced partly in response to an incident, which was an
MRH-90 formation near collision. A significant or serious incident there.
We then went through a process – or the ADF then went through a process
of acknowledging that, assessing that, and decided that a regulatory
40 response was required. Correct?

GPCAPT POUNCEY: Yes, sir.

AVM HARLAND: That regulatory response commenced in June ‘22,

45 some 18 plus months after that particular incident.

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 GPCAPT POUNCEY: Yes, sir.

AVM HARLAND: At that stage, the Aviation community was alerted and
5 given a draft of the regulation.

GPCAPT POUNCEY: Yes, sir.

AVM HARLAND: That was in June 2022. And then the process went
10 through, and I understand that in February ‘23 the regulation was issued.

GPCAPT POUNCEY: Yes, sir.

AVM HARLAND: And at that stage, the community was given

15 nine months to implement it.

GPCAPT POUNCEY: Yes, sir.

AVM HARLAND: This is a safety regulation; correct?

20
GPCAPT POUNCEY: As are all DASRs, yes sir.

AVM HARLAND: And it’s a regulation which is based on, in part, a

significant incident where two MRH-90s almost collided?
25
GPCAPT POUNCEY: Yes, sir. And also not unique to this regulation, but
yes, sir.

AVM HARLAND: So two questions. The first one is, was there any
30 interim guidance or otherwise given to the Aviation community to alert
them of this risk and either encourage or direct them to take measures to, I
guess, immediately address this safety concern?

GPCAPT POUNCEY: I’ll just refer to my statement, sir.

35
AVM HARLAND: Thank you.

GPCAPT POUNCEY: So reference K is an artefact of that nature, sir,

which is the Defence – rather, the DFSB Aviation Safety Investigation
40 Report. And that report – that investigation commenced shortly after the
event that we’ve been referring to on 11 November 2020. Director DFSB
is the relevant Director for questions on that report, but what I can say is
that that report included a number of recommendations to AVNCOMD, sir.

45 AVM HARLAND: Are you aware if any of those were taken up?

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 GPCAPT POUNCEY: No. That’s a question for AVNCOMD, sir.

AVM HARLAND: My concern here is that as a regulator we’ve – or the

5 regulator has identified a serious issue here and yet, unless we’re presented
otherwise, there appears to have been no action taken for quite some time.

GPCAPT POUNCEY: Sir, I wouldn’t characterise it as no action. So

certainly DFSB initiated an Aviation Safety Investigation Team, which led
10 to the Aviation Safety Investigation Report referred to at reference K, in
short order after the event occurred. DFSB is not a Regulatory Director
within DASA, but once the relevant Regulatory Directorate,
i.e. DAVN Ops, my Directorate, had access to the completed and cleared
report, then we included planning for an update to DASR SPA.55,
15 informed, amongst other things, by that report referred to at reference K.

And then as we’ve already established, in 2022, once capacity allowed in

that team – and of course, we update other Defence Aviation Safety
regulations informed by other safety intelligence – we commenced that
20 process I’ve described this morning, sir. So I don’t think it’s accurate to
say that no action was taken. An investigation report, led by DFSB, was
undertaken almost immediately. And shortly thereafter that report was
concluded, the DAVN Ops commenced work on an update to the
regulation, sir.
25
AVM HARLAND: Yes, I wasn’t inferring there was no action. I was
actually trying to explore what actions might have been taken in the interim,
and perhaps we need to explore that with DFSB and with Avn Command
as we moved forward. One final question:in terms of publishing the
30 regulation in February ‘23, and given the seriousness of the background to
re-writing this regulation, did you feel that nine months was somewhat
casual in terms of the implementation?

GPCAPT POUNCEY: No, sir. Typically, a transition period is

35 12 months, and we shortened that to nine months, allowing for the change
to the battle rhythm, if you like, for publications/regulations, and so that
there wouldn’t be a further three-month delay. So, no, sir, we did not
consider that it was casual; it was conventional.

40 AVM HARLAND: And is safety risk a consideration when you set the
timeframe for implementation, or is it done purely on your battle rhythm?

GPCAPT POUNCEY: So there are opportunities to conduct out-of-cycle

DASR releases. We consider safety risk amongst – in other places when
45 we are setting the schedule for major updates to DASR. And, certainly,

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 DASR SPA.55 was brought forward in the overall deliberate review of
Defence Aviation Operations regulations as a result of the associated risk,
sir.

5 AVM HARLAND: Okay, thank you. COL Streit.

MS McMURDO: Well, just before – one more question from me.

Reference L was also a reason for the regulation, another DFSB report. Do
you recall, in broad terms, what that was about?
10
GPCAPT POUNCEY: Yes, ma’am. Reference L refers to an event where
a sequel R on a visual approach at night-time to the deck of
HMAS Brisbane in the Philippine Sea, experienced an NVG bloom;
i.e., that a sailor on the deck of HMAS Brisbane turned on an infrared
15 inspection light at an inopportune moment during the aircraft’s approach,
which caused the bloom in the crew’s goggles, and then the crew
subsequently had a controlled flight into terrain and escaped the helicopter
which then sank to the bottom of the Philippine Sea.

20 MS McMURDO: Thank you. And that wasn’t involving TopOwl

equipment?

GPCAPT POUNCEY: That would be a question for DFSB, ma’am.

25 MS McMURDO: Thank you. Yes, COL Streit. Thank you.

COL STREIT: Thank you. Group Captain, your statement goes on to deal
with matters – paragraphs 16 – dealing with the DASR role in the
continuing operation of the MRH-90 – and 17. Those matters formed part
30 of the evidence before the Inquiry and, because they form part of your
statement – I don’t propose to ask this witness any questions in relation to
those matters. And so, in those circumstances, noting the time, I have no
further questions for this witness.

35 MS McMURDO: Could I just clarify, when did you become – your current
role, when did you take that up, as DAVN Ops?

GPCAPT POUNCEY: In January of 2023, ma’am.

40 MS McMURDO: Thank you. Yes, any applications to cross-examine?

Yes. How long do you expect to be?

LCDR GRACIE: Ten minutes, ma’am.

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 MS McMURDO: Ten minutes. All right. I’ll give you a warning, I think,
today.

LCDR GRACIE: Eight?

5
MS McMURDO: Eight. I’ll give you a warning at eight.

LCDR GRACIE: Thank you.

10
<CROSS-EXAMINATION BY LCDR GRACIE

LCDR GRACIE: Group Captain, sir, my name’s LCDR Malcolm Gracie.

15 I represent the interests of CAPT Danniel Lyon. I appreciate that your
statement’s at a very high level, and because of that I’ve just got some very
basic questions to try and flesh out. I know that the Air Vice-Marshal
mentioned the MRH-90 formation which suggested that there were two
MRH-90s involved but, Counsel Assisting, you referred to an MRH-90 and
20 another aircraft. Can I just confirm they were both MRH-90s?

GPCAPT POUNCEY: So the incident formation described in reference K

was a large formation which included an MRH-90 element and elements of
other aircraft types. The two aircraft which passed in close proximity to
25 each other were both MRH-90s.

LCDR GRACIE: Thank you. And if I do understand the regulatory

change in SPA.55 NVIS, is it only dealing with the part of the system that
comprises TopOwl?
30
GPCAPT POUNCEY: No, sir.

LCDR GRACIE: So it applied to ANVIS, night-vision?

35 GPCAPT POUNCEY: It would apply to any night-vision imaging system

used in Defence Aviation, yes, sir.

LCDR GRACIE: So although it was an MRH-90 incident that triggered

the review process, this applied across the TopOwl system and the more
40 traditional ANVIS night-vision goggles?

GPCAPT POUNCEY: That’s true.

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 LCDR GRACIE: And again, I apologise, because you’ve provided a lot
of references but they’re not part of your statement, so it’s a little bit hard
to know when one reads para - - -

5 MS McMURDO: The references are – you mean the actual document?

LCDR GRACIE: Sorry, yes, the actual document.

So just doing my best to work through paragraph 12 and 13 where you’ve

10 referred to the references. As far as I can see, the documentation that is
referenced doesn’t go back to, let’s say, 2021 or so, and I want to ask you
something about that period: 2019, 2020, 2021. You were aware, in general
terms, I take it, of the AATES testing in relation to the symbology upgrade
from 4.8 to 5.10 in the TopOwl HMSD?
15
GPCAPT POUNCEY: I am aware. It’s not my area of responsibility and
I would direct any questions in that regard either to LCDR Reinhardt or, if
you’re looking at the regulator’s role, to AIRCDRE Joe Medved.

20 LCDR GRACIE: Look, I appreciate that, and I’m just going to bookmark
them. There was the AATES report of 14 June 2019 in relation to the
symbology upgrade, there was the IITs AATES report of 24 April 2020,
and then the one dealing with the FLIR of 12 July 2021. Now, I appreciate
that they’re not referenced, but would those sort of reports get included in
25 any of the briefings that you have referenced because they do touch on
NVIS issues?

GPCAPT POUNCEY: I would have to take that question on notice and

look back through our scoping and framing documentation.
30
LCDR GRACIE: And, look, I appreciate that you weren’t copied-in the
AATES reports or the OPEVAL, but – so I just wanted to check whether or
not these sort of historical matters do get brought up with incidents that are
triggered by – such as those at ref K and ref L.
35
GPCAPT POUNCEY: What I would say is that certainly references E, F,
H, I and J would provide a documentary trail of any specific reports that
were included in the consideration of the development of DASR SPA.55
ANVIS.
40
LCDR GRACIE: Okay. Thank you very much.

Thank you, sir. Thank you, ma’am.

45 MS McMURDO: Thank you. Any other applications to cross-examine?

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 SQNLDR NICOLSON: Ma’am, I do have a question.

MS McMURDO: Yes.
5

<CROSS-EXAMINATION BY SQNLDR NICOLSON

10 SQNLDR NICOLSON: Sir, I’m SQNLDR Nicholson. I appear for the

Officer Commanding 6 Aviation. I just want to ask you about paragraph 14
of your statement in terms of the expectation about the DASR SPA.55. Do
you understand what flying management system change it would be
adopted into?
15
GPCAPT POUNCEY: The specific changes to the flying management
system resulting from DASR SPA.55 should be questions for the relevant
officers in Avn Command.

20 SQNLDR NICOLSON: Thank you. Thank you, ma’am.

MS McMURDO: Thank you, Squadron Leader. Any re-examination?

Thank you very much, Group Captain.

25 GPCAPT POUNCEY: Ma’am.

MS McMURDO: You’re free to go. Thank you.

GPCAPT POUNCEY: Thank you, ma’am, sir.

30
MS McMURDO: Yes. Next witness?

COL STREIT: Ms McMurdo, I call AIRCDRE Joseph Medved.

35 MS McMURDO: Okay. Thank you.

Just leave that, please. Thank you.

40 <WITNESS WITHDREW

COL STREIT: I note for the record that LCDR Gracie was about
four minutes.
45

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 LCDR GRACIE: I was going to ask for another question.

MS McMURDO: You’ve set a good precedent there, so we’ll look

forward to you keeping it up.
5
LCDR GRACIE: It came about from a strategic (inaudible).

MS McMURDO: Fatigue management. Is that it?

10 CLERK OF THE COURT: Would you like to take an oath or affirmation?

AIRCDRE MEDVED: Affirmation.

15 <AIRCDRE JOSEPH JOHN MEDVED, Affirmed

<EXAMINATION-IN-CHIEF BY COL STREIT

20
MS McMURDO: Help yourself to water if you’d like it.

AIRCDRE MEDVED: Thank you.

25 MS McMURDO: Yes, COL Streit.

COL STREIT: Thank you. Sir, could you please state your full name?

AIRCDRE MEDVED: Joseph John Medved.

30
COL STREIT: I might give you an opportunity to pour yourself a glass of
water while I reorganise my papers. Ms McMurdo, I understand that we
can live-stream to 4.30 today, if that is convenient.

35 MS McMURDO: Thank you.

COL STREIT: Sir, could you please tell the Inquiry your current role?

AIRCDRE MEDVED: Director-General, Defence Aviation Safety

40 Authority.

COL STREIT: Sir, in terms of your appearance here today, did you
receive a section 3 Notice requiring your attendance?

45 AIRCDRE MEDVED: Yes, I did.

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 COL STREIT: Did that Notice also contain some questions to assist you
in the preparation of a statement?

5 AIRCDRE MEDVED: Yes, it did.

COL STREIT: Did you also receive a Guide for Witnesses in IGADF
Inquiries?

10 AIRCDRE MEDVED: Yes, I did.

COL STREIT: A Privacy Notice?

AIRCDRE MEDVED: Yes.

15
COL STREIT: And an extract of the Inquiry’s Directions?

AIRCDRE MEDVED: Yes.

20 COL STREIT: As a result of the section 23 Notice, did you prepare a

statement for your evidence today?

AIRCDRE MEDVED: Yes, I did.

25 COL STREIT: I’ll show you a document, including the annexures. Sir,
just take a moment to satisfy yourself that that is a copy of your statement
that you provided to the Inquiry.

AIRCDRE MEDVED: Yes, it is.

30
COL STREIT: Thank you. Now, your statement is 31 pages in length; is
that correct?

AIRCDRE MEDVED: That’s correct.

35
COL STREIT: It comprises Annexures A through to E; is that right?

AIRCDRE MEDVED: That’s correct.

40 COL STREIT: Annexures B through to E are an “Official: Sensitive”

classification; is that correct?

AIRCDRE MEDVED: That’s correct.

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 COL STREIT: We won’t be addressing matters in those annexures in a
public hearing. If any question I ask of you, or any other person for that
matter, requires you to disclose evidence or information contained in
Annexures B to E, can you indicate that to the questioner and we will need
5 to move into a private hearing?

AIRCDRE MEDVED: I will.

COL STREIT: Now, sir, after submission of your statement to the

10 Inquiry, you also provided the Inquiry an additional document by way of
update to an annexure in your statement. I will just provide a copy of a
document to you now and just ask you to identify it.

AIRCDRE MEDVED: Thank you.

15
COL STREIT: Just take your time to move through the pages of that
document, please, sir.

AIRCDRE MEDVED: Yes, this is correct.

20
COL STREIT: Sir, do I understand correctly that that document that I’ve
just handed to you is the update to what is Annexure A of your statement?

AIRCDRE MEDVED: That’s correct.

25
COL STREIT: Sir, are there any amendments you wish to make to your
statement?

AIRCDRE MEDVED: No, there aren’t.

30
COL STREIT: Ms McMurdo, I tender the statement of AIRCDRE
Medved of 31 May 2023 (sic), inclusive of Annexures A to E, and the
addition of the document I’ve just taken the Air Commodore to, which is
an addition to Annexure A.
35
MS McMURDO: Yes, the statement of AIRCDRE Medved, including the
additional material to Annexure A, will be Exhibit 49 (sic).

40 #EXHIBIT 48 - STATEMENT OF AIRCDRE MEDVED,

INCLUDING ADDITIONAL MATERIAL TO ANNEXURE A

COL STREIT: Thank you. Sir, it probably would assist if you are able to
45 decouple the annexures from your statement and put them to the side so

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 they’re out of the way. So I won’t be asking you questions in relation to
those annexures, but I will be taking you through your statement.

Sir, can I begin by asking you some questions about your background. I
5 propose just to read out aspects of your background and simply ask you to
confirm that what I have said is correct. You’re presently an
Air Commodore, the Director-General of Defence Aviation Safety
Authority since December 2020?

10 AIRCDRE MEDVED: Correct.

COL STREIT: In the period January 2016 to December 2020, you were a
Group Captain at the Director level leading the Defence Aviation Safety
Aviation, Aviation Engineering Directorate and DASA International
15 Recognition Activities of Foreign Military Aviation Authorities. Is that
right?

AIRCDRE MEDVED: That’s correct, or partially correct.

20 COL STREIT: What was incorrect?

AIRCDRE MEDVED: During that time, I was also Officer Commanding,

Surveillance Response of the - - -

25 COL STREIT: Sure. I was just about to read that second sentence. So,
sir, you were also the Officer Commanding of the Capability Acquisition
and Sustainment Group, System Program Office. Is that right?

AIRCDRE MEDVED: Correct.

30
COL STREIT: You were, in that role, responsible for Major Capital
Acquisition and Sustainment of Defence Aviation Surveillance and
Response platforms?

35 AIRCDRE MEDVED: Correct.

COL STREIT: In November 2008 to December 2015, you were a Wing

Commander at the Deputy Director level. You were the Director of the
Engineering and Chief Engineer for the Engineering Management System
40 supporting Defence Aviation Major Capital Acquisitions in CASG?

AIRCDRE MEDVED: Correct.

COL STREIT: And Project Engineering Manager responsible for the

45 introduction of the C-27J Battlefield Airlifter into Defence?

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 AIRCDRE MEDVED: Correct.

COL STREIT: Also, the DASA Deputy Director within the DASA,
5 responsible for developing European Military Airworthiness Requirement
based elements of the current Defence Aviation Safety Regulatory
Framework?

AIRCDRE MEDVED: That’s correct, although the organisation wasn’t

10 DASA at that time; it was Directorate General Technical Airworthiness.

COL STREIT: Thank you. You have listed at 3(d) and (e) other aspects
of your background. At paragraph 4 you’ve listed your qualifications. You
have a Master of Management for the Australian National University; a
15 Master of Engineering Science, Aerospace, the University of New South
Wales; a Master of Science, Aircraft Vehicle Design from
Cranfield University in the United Kingdom; and you have a Bachelor of
Engineering, Aeronautical, from the University of Sydney. That’s correct?

20 AIRCDRE MEDVED: That’s correct.

COL STREIT: At paragraph 5 and onwards, you describe your current

position and principal responsibilities. In broad compass, can you just
explain what they are?
25
AIRCDRE MEDVED: Broadly speaking, I head-up the organisation of
Defence Aviation Safety Authority and that organisation is responsible
primarily for independent safety assurance of Defence Aviation activities,
as well as execution of an independent investigative function of Defence
30 Aviation incidents, or serious incidents or safety events.

COL STREIT: Sir, can I just jump to the back of your statement to
paragraph 77. You note there that the ADF, and wider Defence, has no
jurisdiction regarding an aviation incident which occurs in the public
35 domain. You say this is because the Defence Aviation Safety Framework
established by the Joint Directive 21 of ‘21 by the Secretary of Defence and
the CDF has no legislative basis. Consequently, DFSB established under
the Defence Aviation – sorry, DASF. What does DASF stand for?

40 AIRCDRE MEDVED: Defence Aviation Safety Framework.

COL STREIT: Thank you –

under the Defence Aviation Safety Framework as Defence’s

45 independent accident and investigative capability has no statutory

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 power to protect when compared with the Australian Transport
Safety Bureau, its civilian counterpart, which does, deriving its
authority from the Transport Safety Investigation Act 2003. This
means the DFSB has no legal authority or powers to secure a crash
5 site compared with the ATSB.

So in terms of – beginning with the – if we come back to the start of your

statement. At paragraph 5, in terms of beginning with the framework of the
Defence Aviation Safety Authority, the key document that creates the
10 document and gives its authority to do what it does is essentially the Joint
Directive issued by CDF and the Secretary for Defence.

AIRCDRE MEDVED: Correct.

15 COL STREIT: And everything else is simply sitting – every other policy
document is simply sitting under that Directive.

AIRCDRE MEDVED: Correct.

20 COL STREIT: The core functions of the Defence Aviation Safety

Authority include – and this is at 5(b) of your statement – setting safety
policy, standards and regulation, promotion for education, training and
dissemination of information, certification of people, products and
organisations, and oversight and enforcement, and the effectiveness of the
25 independent and investigative performance of the DASA Defence Flight
Safety Bureau, inclusive of education, investigations, analysis and
promotion. That’s all correct, sir?

AIRCDRE MEDVED: That is correct.

30
COL STREIT: Can I just ask how is the effectiveness of the independent
investigative performance of the Flight Safety Bureau – how is that
measured?

35 AIRCDRE MEDVED: We measure it internally within our performance

measurement and monitoring framework, and then we report it through to
the Defence Aviation Safety Board, which performs a governance role
collectively of DASA, which is inclusive of DFSB’s performance.

40 COL STREIT: Can I just take you to the next page, page 4? At
paragraph 7 you provide context to the Defence Aviation Safety
Framework, and particularly you identify at paragraph 8:

The structured Aviation Safety Framework is underpinned by the

45 Defence Aviation Authority, the establishment of the Defence

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 Aviation Safety Authority, the implementation of Defence Aviation
Safety Program, promulgation of effective Defence Aviation Safety
Regulations, and establishment of an independent accident and
incident investigative capability.
5
Just in relation to all of those elements that underpin the Aviation Safety
Framework, can you just explain the role and function of the Defence
Aviation Authority, please?

10 AIRCDRE MEDVED: The Defence Aviation Authority. The Defence

Aviation Authority, which is – the Chief of Air Force is appointed as a
Defence Aviation Authority, and that position – and in that role is
responsible for the safety of Aviation and establishing a regulatory
capability.
15
COL STREIT: Can you assist the Inquiry to understand how – I’ll start
again. Is it important for the Defence Aviation Safety Authority to be
independent of the Services?

20 AIRCDRE MEDVED: Can you clarify what you mean by “independent”?

Well, clarify what you mean by “Services”.

COL STREIT: The three Services: Army, Navy, Air Force.

25 AIRCDRE MEDVED: It is important that the Defence Aviation Safety

Authority is independent of the community, of the Aviation community,
that is responsible for ensuring safety of Aviation operations.

COL STREIT: When you say “Aviation community”, is it not – that’s the
30 Aviation community that sits within those three Services?

AIRCDRE MEDVED: That is correct, but it’s broader than that. It also
includes other non-Service groups, as well as Australian industry.

35 COL STREIT: You mentioned that the Defence Aviation Authority is the
Chief of Air Force.

AIRCDRE MEDVED: The Chief is appointed as the Defence Aviation

Authority, correct.
40
COL STREIT: So the Chief of Air Force wears two hats. One is the Chief
of Air Force; the other is the Defence Aviation Authority.

AIRCDRE MEDVED: That is correct.

45

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 COL STREIT: Is there any document or instrument that facilitates the
Defence Aviation Authority’s independence, separate of the Chief of
Air Force’s functions?

5 AIRCDRE MEDVED: I’m not aware of any instrument that – any separate
instrument from the Chief of Air Force’s responsibilities.

COL STREIT: In the circumstances where DASA is investigating,

whether it be a policy change or an incident involving an Air Force aircraft,
10 is there some means by which you’re aware that there is a separation
between the Chief of Air Force’s functions as the head of Air Force, and
the Chief of Air Force’s – that person’s functions as the Defence Aviation
Authority?

15 AIRCDRE MEDVED: Not that I’m aware of, beyond what’s written in
policy.

COL STREIT: Because the issue I suppose I’m trying to seek your
evidence about is if DASA is investigating an aircraft accident involving an
20 Air Force aircraft, Chief of Air Force ultimately responsible for all
Air Force assets, Chief of Air Force wearing a hat as the head of the
Defence Aviation Authority whose subordinate organisation is conducting
an Aviation investigation, there’s an issue with independence there, isn’t
there, or at least a perception?
25
AIRCDRE MEDVED: I accept that there is, or there can definitely be a
perception of lack of independence. But what I’d further add is in the
absence of a statutory body, it is very difficult to completely remove a
perception of lack of independence by virtue of the organisation residing
30 within Defence.

AVM HARLAND: A quick question. What is your personnel reporting

chain for your performance reporting?

35 AIRCDRE MEDVED: Sir, my reporting chain is through Deputy Chief of

Air Force; however, I have a direct line to Chief of Air Force as the Defence
Aviation Authority for any emergent safety issue, or if there is a need to
make contact.

40 AVM HARLAND: So who writes your annual reports?

AIRCDRE MEDVED: Deputy Chief of Air Force.

AVM HARLAND: Does anybody else do another part?

45

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 AIRCDRE MEDVED: Chief of Air Force, as my second line assessor.

AVM HARLAND: The Chief of Air Force and the Deputy Chief of Air
Force do your annual assessment.
5
AIRCDRE MEDVED: Correct.

AVM HARLAND: Thank you.

10 COL STREIT: Sir, this is not relevant to your military career, but can you
just explain in broad terms whether a person appointed to your position as
the Defence Aviation Safety Authority, the Director-General Defence
Aviation Safety Authority, can that person be posted – at the completion of
that posting, be posted to another part of the ADF to continue their Military
15 Service?

AIRCDRE MEDVED: Yes, that’s possible.

COL STREIT: Does that happen, in your experience?

20
AIRCDRE MEDVED: Yes, it has. I guess I’d just like to add, albeit less
of the historical people in the position I now reside in – it’s been fewer
people that have continued on in other posts, and people are separating at
the end – the conclusion of their posting.
25
COL STREIT: At paragraph 10 you deal with the Defence Aviation
Safety – sorry, what does the “DASP” stand for?

AIRCDRE MEDVED: Defence Aviation Safety Program.

30
COL STREIT: Program?

AIRCDRE MEDVED: Program.

35 COL STREIT: Thank you. Defence Aviation Safety Program functions

and responsibilities. So the first is the prescription and interpretation of
Aviation Safety Management Policy, inclusive of DASR and related
Standards. If I pause there. Does that also involve consideration of
international civil aviation standards?
40
AIRCDRE MEDVED: It definitely does consider, and a lot of our
standards that are recommended are based on best practice international
standards.

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 COL STREIT: There’s also the issuance of authorisations, including
permits, approvals and licences, to certify that Defence Aviation platforms,
systems, organisations and personnel have shown compliance with the
applicable DASR. Is that correct?
5
AIRCDRE MEDVED: That is correct.

COL STREIT: In relation to MRH-90, as it was operating in July 2023,

pilots were using a night-vision system called TopOwl. To your
10 knowledge, did the Defence Aviation Safety Authority perform any
function in the approval of TopOwl?

AIRCDRE MEDVED: Yes, DASA did approve that major change to type
design.
15
COL STREIT: So that’s the major change - - -

AIRCDRE MEDVED: To the aircraft type design. Because that system is

considered part of the aircraft type design.
20
COL STREIT: Are you aware whether DASA approved a software
upgrade - - -

AIRCDRE MEDVED: Version 5.10, yes.

25
COL STREIT: Do you know when that approval occurred?

AIRCDRE MEDVED: In 2018, if I recall correctly.

30 COL STREIT: That was the upgrade to version 5.10.

AIRCDRE MEDVED: Correct.

COL STREIT: That’s the version of TopOwl which was extant on

35 MRH-90 in July 2023; is that correct?

AIRCDRE MEDVED: That is my understanding.

COL STREIT: You weren’t the DG of DASA at the time in 2018, I take
40 it?

AIRCDRE MEDVED: No, I was not.

COL STREIT: In terms of the Defence Aviation Safety Authority, it

45 would have records, would it not, in relation to that approval process?

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 AIRCDRE MEDVED: We do have records of our approval and also our
internal justification.

5 COL STREIT: So the Inquiry, in due course, will be able to obtain those
by the issuance of an appropriate notice?

AIRCDRE MEDVED: Yes, you will.

10 COL STREIT:

One of the other independent safety assurance processes applied

by DASA is the ongoing oversight and enforcement activities to
assure compliance with DASA and the continued validity of
15 authorisations issued by DASA.

So is that a reference to Airworthiness Boards?

AIRCDRE MEDVED: No, it is not.

20
COL STREIT: What’s it a reference to?

AIRCDRE MEDVED: It’s a reference to the functions that DASA as a –

in performing its regulatory role – or in performing one of its regulatory
25 roles.

COL STREIT: Can I take you to paragraph 14, sir, please? You say there
that:

30 DASA must manage the DASR on behalf of the Defence Aviation

Authority. In doing so, DASA must, amongst other things, ensure
that the Defence Aviation Authority is afforded adequate oversight
and control of DASR amendments that may appreciably increase
the compliance burden or appreciably reduce Aviation safety.
35
Could you just break that down into layman’s terms what that means?

AIRCDRE MEDVED: Sure. I guess before I do that, I’ll provide some

context – and it’s clearly annotated in my statement – but DASA is not a
40 legislative regulator.

COL STREIT: Yes.

AIRCDRE MEDVED: However, we do model ourselves on Australian

45 government advice to government regulators that are legislated, and we

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 apply regulation impact analysis as part of our process. Now, what that
means is that if you are putting a control or a regulation or additional
requirements on a community, the burden associated with compliance is
commensurate or not grossly disproportionate to the benefit you receive.
5
So, for example, in an Aviation safety perspective, if we are placing an
additional burden of compliance from the community – and that’s
regardless of whether it is the Military Flying Organisations or even if it’s
an Industry Maintenance Organisation – that the additional burden must be
10 commensurate and not grossly disproportionate to the safety benefit.

That comment also puts – flags that if we do make a change or if we are –

and if I use colloquial language here – if we’re removing red tape and
stripping out regulation, that in doing that process, we’re not appreciably
15 reducing safety outcomes.

COL STREIT: So regulating what needs to be regulated for safety

purposes, but not over-regulating, which just creates an unnecessary
administrative burden on people.
20
AIRCDRE MEDVED: There has to be a demonstrable benefit for putting
that burden on the community.

COL STREIT: Do I understand this correctly:DASA sets the regulation

25 or the parameters of the regulation in the way the regulation is issued and
its language, but it’s the users of that regulation who then have to set the
policies to meet the regulation standard?

AIRCDRE MEDVED: Counsel, can you clarify what you mean by the
30 users setting the policy?

COL STREIT: So DASA sets a regulation for the conduct of night flights
in low illumination. That then requires the – a Command operating aircraft
to have its own policies in place, flying instructions or similar, to reflect and
35 give effect to the DASA regulation. Would you agree with that?

AIRCDRE MEDVED: I wouldn’t say “give effect”. I’d say “to

demonstrate compliance with”. And what I’d also flag, when we talk about
regulations, there are the regulations and then, supporting that, we do have
40 guidance material as well as acceptable means of compliance. Guidance
material is non-binding explanatory material. Acceptable means of
compliance – like the words suggest, it gives examples of how the
community can comply with the regulated requirement. That’s important
because when a community develops their policy, for example, they don’t
45 need to prove that that is – they don’t need to prove that that satisfactorily

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 addresses the requirement if it’s consistent with the acceptable means of
compliance.

Now, whilst we have acceptable means of compliance, that does not

5 preclude the community from offering alternate approaches if it suits their
operations or their business.

COL STREIT: Thank you for that. We will return to that topic because
the fatigue management regulation will be something I’ll take you through
10 which might demonstrate that by way of example. Now, could I take you
to paragraph 15, please, where you set out the DASA function and issue
authorisations. When you refer to 19(c), second dot point, you identify:

DASA must only issue authorisations to applicants that have a

15 contractual relationship with Defence or a Defence contractor and
where that contractual relationship permits enforcement of the
DASR by the Defence Aviation Safety Authority.

Is that correct?
20
AIRCDRE MEDVED: That’s correct. But I would also flag there are –
that it can extend beyond that point, with that fifth bullet point, where it –
and it states, “where it is in Australia’s interest to do so”.

25 COL STREIT: Sure.

AIRCDRE MEDVED: So, for example, we have issued a number of

authorisations to industry organisations that are not directly contracted by
Defence.
30
COL STREIT: One organisation that has been directly contracted by
Defence in relation to MRH-90 is Airbus. That’s right?

AIRCDRE MEDVED: That is correct.

35
COL STREIT: So Airbus have been issued, have they, at least to your
knowledge, with authorisations under the Defence Aviation Safety
Regulation to perform their particular functions?

40 AIRCDRE MEDVED: That is correct.

COL STREIT: Can I turn to paragraph 16, please, which deals with
conduct and oversight? There you say:

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 DASA must conduct inspections, monitoring and investigations as
necessary to assure compliance with the DASR and the ongoing
validity of authorisations it has issued.

5 Could I just ask, in relation to conduct of inspections, can you just explain
in broad compass how that occurs in terms of a process?

AIRCDRE MEDVED: In terms of the process, it involves a desktop

analysis – or dependent on the organisation. And I’ll give an example of a
10 Maintenance Organisation, because that’s probably something people can
more readily relate to. So for an Aircraft Maintenance Organisation, DASA
will do its preparation, look at any artefacts, so look at any available
information on the performance of that organisation, that Maintenance
Organisation. They will look for any trends on other aircraft types, because
15 often we have an industry player that might support multiple aircraft types.

Based on what DASA has seen across industry more broadly, that will
provide information to identify target areas of compliance with the
regulations. There will be a desktop of procedures, and then there will
20 typically be face to face. For example, with Maintenance Organisations,
it’s not only face to face with key position holders in that organisation, but
it’s critical to sight the actual venues where maintenance is conducted
because there’s a lot of content and context that can be attained just through
visual cues and witnessing the conduct of maintenance in the designated
25 maintenance venue.

And post that, there will be an assessment of compliance. And when we

look at compliance, we’re looking at the effectiveness. It goes beyond a
simple black and white, “Was it strictly in accordance with the
30 regulations?” And then there will be a list of discoveries, if you like, from
what occurred in that audit, and, following that, an assessment of those
discoveries or findings to determine if there are any non-compliances. And
there will be a rating associated with those non-compliances, dependent on
their significance.
35
COL STREIT: Can I just ask this? In terms of the teeth that DASA has
to enforce the regulation or provide consequences if there is a breach of the
regulations, subject to the level of seriousness of course, DASA has the
authority to remove a Command’s authorisation to fly an airframe if it fails
40 to comply with the regulation’s requirements?

AIRCDRE MEDVED: In theory, yes. But Command still have flexibility

provisions where they could still continue to operate. And it states in our
policy that if we were to consider a revocation or suspension of an approval

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 that has capability impacts, we would engage the relevant two-star or
Band 2 head of the lead organisation before we pursued such action.

COL STREIT: Because that would have broader capability impacts for
5 the ADF potentially being able to deliver capability to meet government’s
needs?

AIRCDRE MEDVED: It would, but it’s not unprecedented. For example,

on this capability, the Dutch Military Aviation Authority did suspend its
10 maintenance approval for one of their key suppliers, which was the Fokker
company, and that impacted the availability of undercarriages for a period
of time.

COL STREIT: So the nuclear abolition is there, but there’s a lot of steps
15 to go through before it’s ceased?

AIRCDRE MEDVED: It’s a graduated enforcement approach, yes.

COL STREIT: Can I just take you to your organisational structure, please,
20 which appears on page 9? So that diagram reflects your position as the head
of the organisation. You have a headquarters immediately under you, and
then you have six directorates reporting to you:the Defence Flight Safety
Bureau, the Directorate of Initial Airworthiness, the Directorate of
Continuing Airworthiness, the Directorate of Aviation Operations, the
25 Directorate of Aviation Engineering; and the Directorate of Space. Have I
said those correctly?

AIRCDRE MEDVED: That’s correct.

30 COL STREIT: Can I take you to paragraph 20, please? At

paragraph 20(a) you say that the – you, as the DGDASA, the principal
authority on matters concerning implementation of the Defence Aviation
Safety Program – that you’re a delegate of the Defence Aviation Authority
to approve amendments to the Defence Aviation Safety Program
35 Manuals 2 and 3, including approval of all Defence Aviation Safety
Regulations.

I just pause there. So it’s a function of your position as the DG that you
approve all amendments to Defence Aviation Safety Regulations?
40
AIRCDRE MEDVED: That is correct. However, if there is a major
change to regulations, and there’s an appreciable impost, as we discussed
earlier, or a reduction in Aviation safety outcomes, that needs – there needs
to be a Regulatory Impact Statement which must be approved by the
45 Defence Aviation Authority.

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 COL STREIT: What about in relation to the creation of a new regulation,
is your position the authorising or signing authority for a new regulation?

5 AIRCDRE MEDVED: At what stage?

COL STREIT: Take the Aviation Fatigue Management Regulation which

came into effect in, as I understand it, about 2021. Is that right?

10 AIRCDRE MEDVED: That’s correct.

COL STREIT: So you weren’t the DG of DASA at the time, were you?

AIRCDRE MEDVED: I was the DG.

15
COL STREIT: So when that regulation came into effect, was that a
regulation you approved as a new regulation, or was it approved by
somebody else?

20 AIRCDRE MEDVED: I did not approve the regulation because, at the

time, my position did not have that authority. And there were changes made
in July ‘22 which changed the delegations’ framework.

COL STREIT: Prior to the change in delegations, who had the delegation
25 to - - -

AIRCDRE MEDVED: It was the Defence Aviation Authority.

COL STREIT: I see. Separate to the Aviation Safety Management

30 Regulation in 2021, did you have any other delegations concerning bringing
into force a new regulation?

AIRCDRE MEDVED: Yes, I did. So I had scope for all changes to Initial
and Continuing Airworthiness regulations, both development and approval.
35
COL STREIT: So that’s all changes to existing regulations?

AIRCDRE MEDVED: And/or introduction of additional regulations.

40 COL STREIT: Thank you. I’m just trying to understand why – well, do
you know the reasoning processes to why then you didn’t have the
delegation concerning the Fatigue Management Regulation?

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 AIRCDRE MEDVED: The reason I didn’t have a delegation is based on
historical evolution and split of regulations, and which positions were
empowered to make approval of those changes.

5 COL STREIT: As you sit here today, to your knowledge, does the
Defence Aviation Authority hold a delegation to amend a Defence Aviation
Safety Regulation?

AIRCDRE MEDVED: The Defence Aviation Authority, by definition, can

10 approve change to a regulation even today. However, that position has
delegated that authority to – or positional delegation to DGDASA position.

COL STREIT: Can I turn to the Director of the Defence Flight Safety
Bureau. You set out, at paragraph 20(c), a description of the DFSB role and
15 responsibilities. Is it correct that the – I withdraw that. Where you record
in your statement that Director of Defence Flight Safety Bureau is
responsible for independent Aviation accident and incident investigations,
how is that independence obtained or manifest?

20 AIRCDRE MEDVED: Independence is established through a separate

delegation, positional delegation, from the Defence Aviation Authority to
the Director of DFSB to conduct investigations. So although I administer
all of DASA, I do not have direct involvement with investigations.

25 The Director of the Defence Flight Safety Bureau has a personal delegation
to conduct – or it states in that delegation responsibilities that Defence
Flight Safety Bureau is responsible to conduct all accident investigations
and other Aviation safety events and issues. The delegation also includes
the ability to conduct those without Command approval.
30
COL STREIT: Thank you, sir. Can I take you to 20(d) where you deal
with the Director of Aviation Operations and you set out the role of the
Director of Aviation Operations as the formulation and interpretation of
policy, regulations and standards for aircraft operations, uncrewed aircraft
35 systems, air navigation services and aerodromes.

You also identify education, the issue of organisational approvals,

associated oversight and enforcement are also matters within their
bailiwick. You then deal with the Director of Initial Airworthiness and the
40 Director of Continuing Airworthiness. In relation to the Fatigue
Management policy I referred to earlier, the regulation, does that sit with
the Director of Aviation Operations as the organisation facilitator?

AIRCDRE MEDVED: Yes, the regulation associated with Aviation

45 fatigue management does reside within the remit of Aviation Operations

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 because that regulation is only applicable to aircrew and Air Traffic
Controllers.

COL STREIT: Sir, I’m just going to show you two documents. I’ll
5 provide them to you together, and then I’ll identify them separately.

AIRCDRE MEDVED: Thanks.

COL STREIT: Can you just take a moment to look at those two
10 documents and then I will ask you some questions. The first document that
you have, is that the Defence Aviation Safety Regulation, Aviation Fatigue
Management Regulation, printed as of – I can’t read the date.

AIRCDRE MEDVED: 8 August ‘24.

15
COL STREIT: Thank you. I’ve got a staple interfering in that but thank
you for that. Now, can you just explain that document? What is it?

AIRCDRE MEDVED: The document contains the regulations associated

20 with Aviation fatigue management as it’s called out by a number of other
regulations, so for flight operations, air navigation service providers, and
air battle management. The regulation contains the high-level regulations
guidance material, as I explained before, and acceptable means of
compliance.
25
MS McMURDO: The date you read out, I suspect that’s the date it was
printed.

COL STREIT: Yes.

30
MS McMURDO: It was only yesterday.

COL STREIT: Yes. Sir, you provided this document in a PDF form to
the Inquiry, didn’t you?
35
AIRCDRE MEDVED: That’s correct.

COL STREIT: Now, just in relation to obtaining access to the document,

so I take it did you access the Defence Aviation Safety internet website?
40
AIRCDRE MEDVED: That’s correct.

COL STREIT: By gaining access to that website, you were able to

examine the Defence Aviation Safety Regulation.
45

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 AIRCDRE MEDVED: That’s correct.

COL STREIT: When you examine the regulation for Aviation fatigue
management, the regulation appears in a particular format where you have
5 to click on certain links which then drop down certain information.

AIRCDRE MEDVED: That’s correct. Colloquially known as Twisties,

but that’s correct.

10 COL STREIT: Twisties. I’ve learnt something today. Thank you. On

the first page you have (a), and then:

This regulation applies to organisations operating with approvals

granted under –
15
and then it continues. And (b), if you go to the end of (b), you will see a
little blue arrow or triangle pointing downwards and the letters “GM” next
to it. What does the “GM” stand for?

20 AIRCDRE MEDVED: Guidance material.

COL STREIT: So is it the case that if you went to that link, clicked on a
little arrow, then the information that appears in the box immediately under
the letters GM would appear?
25
AIRCDRE MEDVED: Correct.

COL STREIT: All that’s occurred throughout the regulation is that

effectively you’ve clicked on all of the links, GM and ACM, so that all of
30 the information is then extrapolated relevant to the regulation?

AIRCDRE MEDVED: That’s correct.

COL STREIT: Now, if we were to turn the page and go to where you can
35 see 2, 3(b), the number 2 says:

Be integrated with the organisation’s DASR.SMS solution.

Then you have a triangle pointing downwards, “GM”. Then another

40 triangle pointing downwards, “AMC”. First, what does “AMC” stand for?

AIRCDRE MEDVED: Acceptable means of compliance.

COL STREIT: If you click on the AMC, it drops down the information
45 for acceptable means of compliance?

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 AIRCDRE MEDVED: That’s correct.

COL STREIT: That appears in a box immediately under the AMC,

5 doesn’t it?

AIRCDRE MEDVED: Immediately underneath the regulation, yes.

COL STREIT: Yes. So coming back to your earlier evidence where the
10 regulation identifies a particular standard, DASA will provide guidance as
to acceptable means of compliance. That is, if a Command adopts that
acceptable means of compliance, whatever it is, then DASA would consider
that the Command is complying with the regulation?

15 AIRCDRE MEDVED: I would phrase it as the Command, or the

community, has confidence that what they do is compliant with that
regulation, yes.

COL STREIT: So they don’t have to reinvent the wheel because DASA
20 has already identified what is the Acceptable Means of Compliance policy?

AIRCDRE MEDVED: Yes, and there may be more than one acceptable
means of compliance but it’s non-exhaustive. So there may be other
acceptable or alternate means of compliance that may be suitable.
25
COL STREIT: Can I just ask you to look at the second document I
provided to you. We will come back to this document in a moment. But
the second document, can you just explain what that second document is?

30 AIRCDRE MEDVED: So the second document is a summary of change

whenever we issue updates to our policy, inclusive of regulation. Currently
we release updates to our regulations every six months, and what
accompanies that on the same day of release is a summary of the change
and then a detailed content describing the change. This summary of change
35 covers the release on 28 October ‘21, which included the introduction of
the Defence Aviation Safety Regulation, Aviation Fatigue Management.

COL STREIT: So when a person accesses the Defence Aviation Safety

Regulation via the internet and goes to the Aviation Fatigue Management
40 policy, that person can also go to the area which addresses the amendments
to the regulation, locate the summary of change document relevant to the
Aviation Fatigue Management Regulation, and identify with a level of
confidence as to when the regulation came into effect?

45 AIRCDRE MEDVED: Correct.

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 COL STREIT: So what this summary of change document reveals is that
at paragraph 2, the Aviation Fatigue Management Regulation was a new
regulation and came into effect in October 2021. Am I reading that
5 correctly?

AIRCDRE MEDVED: You are.

COL STREIT: We return now to the Aviation Safety Fatigue

10 Management Regulation. You will see under GM, which is at (b) – what’s
“GM” again, sorry?

AIRCDRE MEDVED: Guidance material.

15 COL STREIT: Thank you. I’ll get the hang of this soon.

MS McMURDO: (Indistinct).

COL STREIT: Before it changes. At paragraph 1:

20
Purpose/Context: Under the Workplace Health and Safety,
Accountability Managers are accountable for the fatigue
management of all staff, at all levels, of the command chain with
their scope of control, including unit Commands. Personnel who
25 are identified as safety-critical positions are required to perform
under high levels of stress and work periods without the ability to
rest are subject to fatigue-induced human factor errors that may
comprise Aviation safety.

30 Regulating fatigue management practice for specific employment

groups can provide independent assurance of controls that are
designed to minimise fatigue-related human factor errors in
Defence Aviation.

35 So the Workplace Health and Safety Act is a piece of legislation that is front
and centre for the Defence Aviation Safety Authority in the construction of
its regulations insofar as fatigue management is concerned?

AIRCDRE MEDVED: Not insofar as fatigue management is concerned,

40 no. The reason WHS Act is flagged here and also within the Defence
Aviation Safety Framework policy is that we don’t – our Aviation Safety
Framework is not legislated like in civil aviation.

COL STREIT: Sure.

45

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 AIRCDRE MEDVED: So in civil aviation there’s a Civil Aviation Act.
And under international conventions for aviation there’s a separation of
civil aviation from state-based aviation. And, in Australian context, that’s
Military Aviation. So we model ourselves on civil practices, standards and
5 recommended practices but tailored, clearly, within a military context.

Defence is subject to the WHS Act and because the WHS Act was never
designed to account for Aviation safety, because it does not apply in civil
aviation at all, there is no applicable code of practice, for example, for
10 Aviation in the WHS Act. So given that Defence is subject to WHS Act,
we have set up the framework, the Defence Aviation Safety Framework, to
amplify our obligations under the WHS Act.

COL STREIT: The Fatigue Management subregulation (2), Aviation

15 Fatigue Management.20.A, Defence Aviation Management Construct
Purpose:

The safe and successful delivery of Aviation system capabilities

supported by effective fatigue management policy.
20
And then it has:

(Hazard) If not properly managed, fatigue can introduce human

factor errors that may compromise Aviation safety.
25
In terms of the word “hazard”, why, to your knowledge, does that appear in
this regulation guidance?

AIRCDRE MEDVED: The reason this is described this way is it’s

30 consistent with the style in how to write regulations and having purposive
regulations. And linking – and from a guidance material in explaining what
the regulation’s about, it gives it context. It identifies the hazard and the
defence is the control, or what we do to mitigate risks from that hazard.

35 COL STREIT: I’d ask you to turn the page, please, and go to the – about
midway down that page, to the box that has “GMAVFM.20.B(2) SMS
integration”. What’s does “SMS” mean?

AIRCDRE MEDVED: Safety management systems.

40
COL STREIT: Thank you. So this identified its purpose as:

How personnel are employed should always be weighed against

their ability to perform without error over the required time
45 periods.

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 The hazard is:

If employment tasks and time periods are not effectively assessed,

5 there is potential for fatigue to create human errors that may
compromise Aviation safety.

And then:

10 (Defence) Two globally accepted significant Aviation fatigue

management controls are the imposition of duty limitations and
rostering practices. However, these two controls alone may not
eliminate or minimise SFARP Aviation Fatigue Risk.

15 I pause there. What does “SFARP” mean, if you know?

AIRCDRE MEDVED: So far as reasonably practicable. And that’s

straight from the WHS Act.

20 COL STREIT: Thank you. I’ll continue:

The integration of fatigue management and SMS ensures that the

future identification and continuous improvement of all controls to
minimise Aviation fatigue risk.
25
Then there’s a box titled, “Contextualisation”. Then if you turn the page,
there’s a box titled, “Use of Benchmark Information”. And the drop down
menu for Benchmark Information says this:

30 A broad range of national and international fatigue management

research regulations and guidance exists for both civil and
Military Aviation with some better than others.

(Hazard) Not considering this benchmark information may result

35 in deficient Aviation fatigue policy that could compromise Aviation
safety.

(Defence) Fatigue management solution suitability is partially

based on access to Defence benchmark information that can assist
40 with development of local contextualised solutions. While
benchmark information from any DASA recognised MAAs and
CAAs –

pause there. What does “MAAs” and “CAAs” mean?

45

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 AIRCDRE MEDVED: Military Aviation Authorities and Civil Aviation
Authorities.

COL STREIT: I continue –

5
can be used to assist with the development of a DASR-compliant
AVMFM solution. The Defence Aviation Fatigue Management
Guidebook has been developed for ADF Aviation Commanders
and Managers, summarising relevant global benchmark
10 information. The Defence Aviation Fatigue Management
Guidebook also aligns with ICAO’s Fatigue Management
Standards and Recommended Practices and reflects Defence’s
unique Aviation fatigue context.

15 So I take it from that “Use of Benchmark Information” box concerning the

Aviation Fatigue Management Regulation, that CASA has identified the –
sorry, CASA – DASA has identified the Defence Aviation Fatigue
Management Guidebook as acceptable means of compliance for a
Command to adopt in addressing the Aviation Fatigue Management
20 Regulation?

AIRCDRE MEDVED: I’ll draw you to the words within that guidance
material, which says that it can be used to assist with the development of a
DASA compliance solution. So you need context to develop a compliant
25 solution for an operator. And that Fatigue Management Guidebook was
developed and is maintained and updated by the Defence Flight Safety
Bureau as part of their research function.

COL STREIT: So without being flippant, DASA has not included

30 reference to the Fatigue Management Guidebook in that part of its
regulation just to take up space; it’s included in there because it’s
important?

AIRCDRE MEDVED: Absolutely.

35
COL STREIT: A Command would, at their own peril effectively, step
away from what DASA is recommending as guidance to assist in meeting
compliance with the regulations, would they?

40 AIRCDRE MEDVED: Counsel, can you repeat that question, please?

COL STREIT: So DASA is telling the world of ADF Aviation in relation

to fatigue management that acceptable means of compliance, a document
that will assist the Command meet the regulation and be acceptable means

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 of compliance is the Defence Aviation Fatigue Management Guidebook.
Would you accept that?

AIRCDRE MEDVED: No, I don’t. Because if you look above where it

5 has “the acceptable means of compliance”, it states that “the Fatigue
Management Guidebook is not considered AMC”. It’s not structured
against the regulation and cannot account for all the different operating
scenarios and contexts, but it helps the community develop regulatory
compliant solutions tailored to their context and operations.
10
COL STREIT: Sure. And that’s why the word “assist” appears there in
that box, doesn’t it? That “the guidebook will assist”?

AIRCDRE MEDVED: I think that’s reasonable. I did not author this

15 regulation, but it seems reasonable, yes.

COL STREIT: Yes. So I’m just picking up on your earlier evidence,

where you stepped back from agreeing with me that its compliance with the
Defence Aviation Fatigue Management Guidebook would be acceptable
20 means of compliance. I understood you to say, “No, it’s simply a document
that assists”?

AIRCDRE MEDVED: Correct.

25 COL STREIT: And my point or suggestion to you is that any Command

would be a bit foolish not to look at the document that the regulatory
authority has identified as being the document that would assist it in
meeting compliance with the regulation.

30 AIRCDRE MEDVED: The way I’ll – I’m not going to use the word
“foolish”, but the way I would interpret that, and my response would be the
regulator would not look favourably upon an organisation, if they had a
non-compliant system, if they had not considered content within the
Aviation Fatigue Management Guidebook.
35
COL STREIT: Because this information that’s in the regulation, which is
the guidance, the regulator is saying that:

The Defence Aviation Fatigue Management Guidebook has been

40 developed for ADF and Aviation Commanders and Managers,
summarising relevant global benchmark information. It also
aligns with the International Civil Aviation Authority’s fatigue
management standards and recommended practices and reflects
Defence’s unique Aviation fatigue context.
45

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 So, accepting that, if you were a Command and you didn’t have regard to
the contents of the Defence Aviation Fatigue Management Guidebook, or
at least have a good reason why you step away from/not comply with it or
use it, you’d run into difficulty, wouldn’t you – if you were a Command,
5 and you’d been assessed for compliance by the regulator?

AIRCDRE MEDVED: You would. Particularly if there was wilful

ignorance of that guidebook.

10 AVM HARLAND: Who does assess Air compliance against this

regulation?

AIRCDRE MEDVED: Directorate of Aviation Operations.

15 AVM HARLAND: And do you know what the result of the last audit was
in terms of its presence, suitability, operating, and effectiveness? What was
the last result?

AIRCDRE MEDVED: I do, because there was an audit in April of this

20 year. There were a number of Level 2 findings. But I don’t recall a Level 2
finding being raised in relation – DASA AVFM, Aviation Fatigue
Management, was within scope of that audit, but I don’t recall a Level 2
finding being raised against Army Aviation Command.

25 AVM HARLAND: That was in April this year. Were there any other
audits done between the time this was published in October ‘21 and
July ’23?

AIRCDRE MEDVED: Yes, there were.

30
AVM HARLAND: Do you know the results of those audits? Or are you
able to summarise them?

AIRCDRE MEDVED: I am able. They’re contained within the DASA

35 submission to the Airworthiness Boards where it summarises all of our
audit outcomes.

AVM HARLAND: Could you give guidance as to where?

40 AIRCDRE MEDVED: So it’s Annex C.

COL STREIT: Isn’t that a document that - - -

MS McMURDO: That’s Annexure C.

45

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 AIRCDRE MEDVED: It is. But in terms of – we can identify whether
there was a finding raised against AVFM and that is – that in and of itself
is not “Official: Sensitive”.

5 COL STREIT: That might assist one of the Counsel representing in the
audience, thank you, in how we might formulate an approach. Can I first
begin by tendering the two documents, Ms McMurdo. I’m sorry, I don’t
remember what exhibit number we’re up to.

10 MS McMURDO: Of course. So the DSR AVFM will be Exhibit 49.

#EXHIBIT 49 - DSR AVFM

15
MS McMURDO: And the summary of change the DASR released
28 October ‘21 will be Exhibit 50.

20 #EXHIBIT 50 - SUMMARY OF CHANGE RELEASED BY DASR

28/10/21

COL STREIT: Ms McMurdo, it’s been drawn to my attention that

25 AIRCDRE Medved’s statement may well be Exhibit 49.

MS McMURDO: I think it’s 48, isn’t it?

COL STREIT: Maybe if the - - -

30
CLERK OF THE COURT: It should be 48.

MS McMURDO: Forty-eight.

35 CLERK OF THE COURT: So that should be 49.

MS McMURDO: No, it was 48. It was always 48.

COL STREIT: Thank you. Counsel Assisting is correct.

40
MS McMURDO: Yes. 48. So 49 is the first document, and 50 is the
second.

COL STREIT: Thank you.

45

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 Sir, can I return to your statement. And if you could put the Aviation
Fatigue Management document and the associated document to one side.
In some respects, sir, you’ve given evidence in relation to other parts of
your statement, and there’s no need to go over those matters. So if I could
5 take you to page 17 of your statement, please.

AVM HARLAND: Have we completed the discussion on whether or not

an audit was done?

10 COL STREIT: In your hands, sir.

MS McMURDO: We obviously can’t go into the details, but he could just

find it in the document and show us where it is. That’s all we require, isn’t
it? Yes.
15
AIRCDRE MEDVED: So Annex C, on page 13, provides the outcomes of
an Aviation Command Oversight and Enforcement Summary from an
oversight of the period of 12 to 22 August ‘22.

20 AVM HARLAND: I guess what I’m really trying to establish is if this was
actually audited specifically, as this Aviation Fatigue Management
Regulation was ordered against, specifically, between October ‘21 when it
was published, and July ‘23.

25 AIRCDRE MEDVED: Sir, I’d have to take that on notice, to look at the
scoping documents – or DASA would need to look at the scoping
documents, with those audits, to confirm the scope of – there were two
audits done – but would need to confirm whether that was within scope.

30 AVM HARLAND: Great. Yes. Thank you. That’ll be very useful.

COL STREIT: Sir, perhaps we could go even further. If I could take you
to paragraph 42 of your statement, which is on page 18. At paragraph 42
you say:
35
Compliance expectations of the regulated community.

I pause there. “Regulated community”, what is that a reference to?

40 AIRCDRE MEDVED: That’s a reference to the Aviation community to

whom the Aviation Safety Regulations apply.

COL STREIT: Is that inclusive of the three services:Army, Navy, and

Air Force?
45

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 AIRCDRE MEDVED: And non-service groups, and industry.

COL STREIT: Thank you. It then says, under the “Accountability”

section:
5
(a) The Vice-Chief of the Defence Force, Service Chiefs, the Chief
of Joint Operations, and group heads, are accountable to the
Secretary and CDF for ensuring the management of Defence
Aviation activities under their control complies with the
10 requirements of this Directive and subordinate Aviation Safety
policy and regulations.

So that’s taken directly out of the Joint Directive 21 or 2021; correct?

15 AIRCDRE MEDVED: Correct.

COL STREIT: And at paragraph 43 – I withdraw that. Can I ask you this?
Where it says the individual positions I’ve just identified are “accountable
to the Secretary and CDF for ensuring the management of Defence Aviation
20 activities”, et cetera, what does that really mean in terms of accountable?
In other words, how is the accountability assessed and enforced?

AIRCDRE MEDVED: I’ll answer the first question: how it’s assessed.

25 COL STREIT: Sure.

AIRCDRE MEDVED: I would state that it’s assessed by DASA’s ability,

first of all, to oversight – to confirm levels of compliance. And, secondly,
the behaviours we witness. And, if there needs to be escalation within – up
30 to that level – up to and including the group head level, that they are
fulfilling or being compliant with the Joint Directive. Now, in terms of
assessment, we have not seen – I’m not aware, in my tenure, of ever seeing
wilful non-compliance throughout an organisation being evident right
through the organisation up to a group head. So that’s taken directly out of
35 the Joint Directive 21/2021; correct?

COL STREIT: Paragraph 43, you say:

DASA consults broadly on major regulation amendments often

40 supplemented with targeted engagement to the regulatory
development process. A significant regulation change will include
an implementation transition period and possible unique transition
arrangement for extant members of the regulated community –

45 and it goes on. So, in effect, a significant regulation change involves

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 engagement with the regulated community in the development of what is to
be the new regulation, or a new regulation?

AIRCDRE MEDVED: Correct. So that would be in the order of, from

5 recent experience in the last few years, at least 12 months, and sometimes
much more.

COL STREIT: Can I take you to paragraph 51, please? This deals with
DASA oversight and enforcement. At paragraph 49 you say:
10
DASR GR60 specifies compliance, oversight and enforcement
obligations and requires all Defence, civilian and contractor
entities operating within the Defence Aviation Safety Regulatory
Framework to comply with a DASR.
15
What happens if they don’t? What can happen to them if they don’t?

AIRCDRE MEDVED: If they don’t comply?

20 COL STREIT: Yes.

AIRCDRE MEDVED: What we look at is our oversight and enforcement

approach, and we have a graduated response dependent on behaviours and
ability to comply as well. And it’s a graduated response. Particularly with
25 a new organisation or new requirements, it starts with an education and
coaching style of approach, then to the provision of findings or corrective
actions, and then that escalates to the point of suspension or revocation.

And without an organisational approval – and I’ll give an example of a

30 Maintenance Organisation – and we saw it with, like, that example I
provided before with Fokker in the Netherlands. They had their approval
to do maintenance on undercarriages of MRH suspended and they were not
permitted to release any items from maintenance. So it prevents you from
conducting the services under that approval. Or similarly, if you think of
35 even a civilian air operator, like an airline, if they lose their Air Operator’s
Certificate, they can no longer conduct flying operations.

COL STREIT: Is there some linkage between the Defence Aviation

Safety Authority and other countries’ equivalent aviation safety authorities
40 in the military context for the operation of same aircraft?

AIRCDRE MEDVED: Yes, there are. There is the International Civil

Aviation Organisation. There is no international Military Aviation
Organisation. So we do have recognition arrangements. Again, modelling
45 off a civilian approach and how they’d recognise national civil aviation

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 authorities, and there are constructs in place where you have multiple
countries operating the same aircraft, as is the case with MRH-90, and the
NH-90 as it’s otherwise more commonly known.

5 COL STREIT: Thank you. Sir, I note at paragraph 58 you deal in some
little detail about sanctions that may be imposed. I simply draw that to the
attention of the Inquiry. Can I move to paragraph 60? This is where you
describe what DASA findings are in relation to a particular process. So can
you just explain the operation of the DASA instruction that you’ve listed
10 there and its purpose?

AIRCDRE MEDVED: The purpose of the instruction is to standardise the

DASA approach for executing the oversight and enforcement function of
different organisations. From the earlier piece of my submission, I stated
15 that the different directorates perform oversight of organisations within
their remit.

So there is a directorate that looks after Maintenance Organisations. A

separate directorate that looks after Design Organisations and another
20 directorate, for example, that looks after Military Air Operators. Not only
is it important for consistency within a directorate, it’s also critical across
directorates that we apply the same approach to conducting oversight and
enforcement with the total community.

25 And by having an instruction that cuts across all of DASA, it ensures a level
of consistency in how we approach oversight, our graduated enforcement
approach, and how we work with the community to address shortfalls.

COL STREIT: Now, that instruction that’s available to members of the

30 ADF, does that sit on the Defence system?

AIRCDRE MEDVED: It does. It sits on a DASA intranet site and it’s an

internal DASA instruction. But anyone with Defence Protected Network
access can access that instruction.
35
COL STREIT: Can I take you to page 26 where you deal with
Airworthiness Boards? Could you just assist the Inquiry by explaining what
is an Airworthiness Board and its purpose?

40 AIRCDRE MEDVED: I’ll need to explain this from a temporal or a

time-based period because the role of the Airworthiness Board has evolved
over time. As I’ve provided in my statement, it’s an Independent Board of
Review to provide assurance that a satisfactory basis – it says
“airworthiness or safety has been established and is maintained”. Though,
45 they were first established – well, the first one was conducted in May 1991,

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 and at that stage we did not have organisations providing regulatory
functions.

So the Board of Review, it comprises of two senior retired officers; one

5 with an operations background and one with a technical background. And
they complement what DASA does as a regulator. And whereas where
DASA is constrained by the scope of the regulations, they have the
flexibility to explore, it seems, within regulations, areas that may have
second order effects to Aviation safety or organisations that are not directly
10 regulated or come under the Defence Aviation Safety Regulations.

COL STREIT: Now, could you just, as you sit here today – well, no, I
withdraw that. As of July 2023, how was an Airworthiness Board
conducted for MRH-90 – the process?
15
AIRCDRE MEDVED: The process is very similar to what is conducted
today. So at the time, it’s a forensic look by these two senior retired – I
may have said Air Force before – I mean ADF Officers, who forensically
review packages provided by the community, as well as a DASA
20 submission which contains DASA’s independent views across all aspects
that we regulate.

When I say that they review a package, that includes established documents
of interest as well as the provision of answers to standardised question sets
25 that have been developed for different types of organisations. So,
for example, there are question sets for Maintenance Organisations.
Maintenance Organisations, that’s both industry as well as ADF. It includes
question sets for Design Organisations, whether they’re in Defence or
industry, and it has question sets for the Flying Organisations as well.
30
MS McMURDO: Could I ask you if you have a look at the diagram on
page 9 of your statement, do the Airworthiness Board sit in that diagram or
do they sit directly under the Defence.

35 AIRCDRE MEDVED: Ms McMurdo, they do not sit within the DASA or

the regulator.

MS McMURDO: Yes.

40 AIRCDRE MEDVED: They sit to the side, and they directly report to the
Defence Aviation Authority.

MS McMURDO: Defence Aviation Authority. Yes, thank you.

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 COL STREIT: So just picking up on that, I was going to ask you first who
selects the persons to comprise the Board, to your knowledge?

AIRCDRE MEDVED: It is the Defence Aviation Authority and every –

5 or, annually, the tenure of existing Board members is reassessed and there
are – if there are subsequent vacancies, there is a succession policy that we
have in place for Board members, and where there are identified candidates
and members who are genuinely interested to become an Airworthiness
Board member.
10
There is a process to assess their suitability that I staff up to the Defence
Aviation Authority, but it requires endorsement by the Airworthiness Board
Panel Chairs. So you have an Operational Chair and a Technical Chair
across the Airworthiness Board Panel members. We have 14 at the
15 moment. So you have a lead for each who provide a coordination and
standardisation function.

COL STREIT: Why is it necessary – what’s the reasoning behind Board

members being retired? Retired from the Defence Force, that is.
20
AIRCDRE MEDVED: Counsel, can you repeat that question?

COL STREIT: I may have misunderstood your evidence earlier. I

understood you to say to the effect that Board members comprised at least
25 one person who was retired.

AIRCDRE MEDVED: They are both Reserve members, so they’re no

longer full-time members of the ADF.

30 COL STREIT: I see. So they’re still members of the Defence Force but
in a Reserve capacity?

AIRCDRE MEDVED: Correct, in a Reservist capacity.

35 COL STREIT: The process of a person’s selection is a process by which

your office staffs to the Defence Aviation Authority for consideration?

AIRCDRE MEDVED: Correct.

40 COL STREIT: The Defence Aviation Authority - - -

AIRCDRE MEDVED: But I do stress, it must require endorsement from

the two Airworthiness Board Panel Chairs and, historically, they had been
referred to as the Airworthiness Board Panel Mentors.
45

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 COL STREIT: Are the two Airworthiness Board Panel Chairs Reservists
as well?

AIRCDRE MEDVED: They are as well.

5
COL STREIT: Who appoints them?

AIRCDRE MEDVED: The Defence Aviation Authority.

10 COL STREIT: Can I take you now, please, to paragraph 67 and onwards.

MS McMURDO: Just before you go on with that, could I just ask you this?
We heard that to amend a regulation or to introduce a new one takes time.
It takes nine, 12, 18 months. I would expect that from time to time,
15 exceptionally, safety issues would arise – sudden, urgent safety issues
would arise. So are they dealt with through this Airworthiness Board
process?

AIRCDRE MEDVED: No, they’re not, Ms McMurdo.

20
MS McMURDO: All right.

AIRCDRE MEDVED: If there is – whilst we do have our battle rhythm of

two updates per year, if there was something of urgency, we could focus
25 our attention on it and we could do an out-of-session approval if required.

MS McMURDO: Through amending the regulation?

AIRCDRE MEDVED: That is correct.

30
MS McMURDO: So that would be done that way, rather than through the
Airworthiness Board?

AIRCDRE MEDVED: The Airworthiness Board has no role or function –

35 now, currently, they have no role or function with the regulatory system.
Previously, they did.

MS McMURDO: Thank you for clarifying that.

40 AVM HARLAND: Just a follow-on. With the DASA SPA.55 NVIS, so

that was assessed as not sufficiently urgent to warrant anything other than
a routine timeline. Is that a correct statement?

AIRCDRE MEDVED: It was prioritised because it was reshuffled in the

45 order of potential updates to the Operational Regulations. So it was by

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 virtue of a number of near misses and an accident, or a near miss and an
accident. And again, this is contained within the documentation as to why
we investigated it. We identified there were insufficient controls and that
was prioritised over other scheduled regulatory updates.
5
AVM HARLAND: So you prioritised that in the order of build, if you like?

AIRCDRE MEDVED: Correct.

10 AVM HARLAND: Is there a prioritisation based on risk to deal with the

order of publishing or, in fact, publishing out of cycle?

AIRCDRE MEDVED: Sir, could you repeat that question?

15 AVM HARLAND: We talked about the fact that you risk managed, in this
case, DASA SPA.55, and prioritised it for work to get to the point where it
was constructive. So that was prioritised in the build schedule, if you like.
What I’m looking at is, when you’re looking at the actual delivery and the
time at which an organisation has to comply, do you base that timeline on
20 risk or is it just based on purely a cadence of delivery of regulations – a
two-year drop, you talk – two per year drop?

AIRCDRE MEDVED: The compliance timeframe – when you say

“compliance timeframe”, that’s not to suggest that the community should
25 not be compliant in a – I’ll start again. The compliance timeframe is
associated when DASA will commence oversight and enforcement against
that regulation. So regardless of whether the community is compliant, the
community is still responsible for ensuring safety. So if they have
significant gaps in their processes, it behoves the community to identify
30 where they are most exposed and to address some of those gaps sooner
rather than later.

AVM HARLAND: That would seem perfectly reasonable. Would you

accept that if an organisation was significantly overtasked – under the
35 pump, if you like – that they may prioritise compliance to the things that
are closer to their current date than further away?

AIRCDRE MEDVED: That sounds reasonable, sir.

40 COL STREIT: Sir, I just want to now briefly deal with matters concerning
MRH-90 and then I’ll have concluded my evidence-in-chief and I’ll be
requesting perhaps an appropriate break at that point in time so I can discuss
a matter with my learned friend as to whether a private hearing is necessary.

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 Sir, paragraph 67 of your statement reflects that since 2007 DASA and its
predecessor organisations have conducted 12 Airworthiness Boards
concerning MRH-90, two Remote Aviation Safety Reviews, and two
out-of-session Airworthiness Reviews on MRH-90 Enterprise. A Board
5 was scheduled for November 2022, but it was postponed to 2023. And,
subsequently, that Board was cancelled following the government
announcement to cease MRH-90 operations in September ‘23. Is that
correct?

10 AIRCDRE MEDVED: That is correct.

COL STREIT: At paragraph 68 you say:

Nine Airworthiness Board Corrective Action Requests have been

15 raised against various parts of the MRH-90 organisations.

First, can you just explain briefly what’s an Airworthiness Board Corrective
Action Request?

20 AIRCDRE MEDVED: That is the Airworthiness Board, when they review

packs, they also, as part of their review, there is a board-style engagement
which can last close to one working day. They also do site visits as well,
for context. When they raise the report, they include things of note –
correction – observations, safety items of note, and concerns. And they are
25 concerns to Aviation safety, whether it be immediate or a significant
concern if nothing is done in the short to medium term.

Dependent on the seriousness of the concern, it may warrant, in the Board

member’s eyes – or justify them to raise an Airworthiness Board Corrective
30 Action Request. They will be responsible for the drafting of it, and then the
Defence Aviation Authority will sign that Corrective Action Request, and
then that is issued to an organisation, regardless of whether they fall under
the DASRs, to address the shortfalls.

35 COL STREIT: Sir, at paragraph 68 you say, in terms of Corrective Action

Requests, five have been closed and four were open at the time of cessation
of operations, but these ACARs were retired when the decision to withdraw
MRH-90 from Service was made.

40 AIRCDRE MEDVED: Correct.

COL STREIT: So at the time of the crash of the MRH-90 in July 2023,
five Airworthiness Board Corrective Action Requests had been closed and
four remained open?
45

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 AIRCDRE MEDVED: That’s correct. And a reminder:that is over the
entire lifecycle of the MRH-90 in Army Service.

COL STREIT: At paragraph 70 you set out common themes across the
5 Airworthiness Board reports concerning MRH-90. I’m going to read them
out. You say:

MRH-90 Airworthiness Board’s summary details a long history of

an Aviation system under stress.
10
You say:

Common themes that are present in most reports are:

15 (a) A developmental aircraft design that was under continuous

design update during production, leading to complex
configuration management issues.

(b) Complex maintenance history that was difficult to transcribe to

20 the Defence Aircraft Maintenance Management System
CAMM2, and a high maintenance burden to maintain
airworthiness.

(c) A target-planned rate of effort for the platform that was not
25 achieved, leading to the inability to maintain aircrew currency
and proficiency.

(d) Complex technical publications for maintenance and aircrew,

compounded by a large burden of temporary updates during
30 operation of the platform.

(e) Inadequate engineering and logistics support arrangements.

(f) An aggregated risk to Aviation safety inclusive of airworthiness

35 that was challenging to characterise and quantify.

Is what I have read out correct?

AIRCDRE MEDVED: That’s correct. And to clarify, with 70(c), the

40 “planned rate of effort” is flying hours, if that wasn’t clear.

COL STREIT: Yes. Thank you.

AVM HARLAND: A question: how many times did MRH-90 cease

45 operations during its life in ADF?

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 AIRCDRE MEDVED: Multiple times, sir. I’ll have to take that on notice
to quantify, but I can recall multiple times across my current stint, and
previous director stint, in DASA.
5
AVM HARLAND: Is that usual?

AIRCDRE MEDVED: The lengths of the cessation was unusual – or was

higher than other platforms.
10
AVM HARLAND: And the number of cessations?

AIRCDRE MEDVED: Sir, I’d have to – anecdotally, yes, but I’d like to
confirm that by comparing platforms with formal cessation. But,
15 anecdotally, yes.

AVM HARLAND: Yes, that would be useful. A following question is

then – I guess it comes down to when we read through paragraph 70 and its
subparas, as COL Streit has done, the question that comes to my mind is
20 where is the line in terms of, you know, ramping up enforcement action, or
saying, “Hey, we’ve really got to stop here”? When does that happen?

AIRCDRE MEDVED: Sir, I think the reflection or – we saw Command

take appropriate action by – as a reflection of the formal cessation of
25 operations that they conducted, as well as the duration of those cessations.
So, for example, in my tenure there was, if I recall correctly, in the order of
a two-month cessation of operations due to lack of confidence that aircraft
had complied with all the maintenance requirements.

30 AVM HARLAND: So the cessation of operations were indicative of a

system that was working?

AIRCDRE MEDVED: I would suggest yes.

35 AVM HARLAND: An Airworthiness that was working?

AIRCDRE MEDVED: Yes.

AVM HARLAND: But a platform which was struggling?

40
AIRCDRE MEDVED: A platform – and I would characterise it as a
platform and associated support arrangements.

AVM HARLAND: Could you just make a comment – or, I guess, provide
45 your opinion on when you see this kind of background for a platform and

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 its history, what sort of follow-on effects does that create for the
organisation in terms of does it make your life easier, does it make your life
worse, does it increase workload and in turn stress?

5 AIRCDRE MEDVED: What we saw, and was clearly evident, that it

dominates the effort of the Command of the Service, and even
disproportionately compared to other platforms. And that was also
reflected in even DASA assurance activities. The effort we expended on
this platform was disproportionate compared to all the other support we
10 provide to other platforms.

AVM HARLAND: That’s helpful. Thank you.

COL STREIT: One final question, sir. To put it into context,

15 paragraph 70, you’ve set out common themes across Airworthiness Board
reports. So that’s Airworthiness Board reports from 2021, backwards in
time?

AIRCDRE MEDVED: Correct.

20
COL STREIT: Because the Airworthiness Board for November 2022
didn’t go ahead.

AIRCDRE MEDVED: That is correct.

25
COL STREIT: And was then postponed into 2023. But because of the
decision to cease MRH-90 operations in September 2023, there was no
requirement for a Board report – an Airworthiness Board – at that time.

30 AIRCDRE MEDVED: That’s correct. The Board was scheduled for early
August. So, after the accident, it was indefinitely postponed until we had
clarity of the outcome of the tragic accident. And then, when there was a
formal cessation of operations announced by government, then the decision
was to cease – well, cease with any planning with that Airworthiness Board.
35
COL STREIT: And just for context, you examined the 12 Airworthiness
Board reports, and the other documents you identify at paragraph 16, to set
out the common themes at paragraph 70. Is that correct?

40 AIRCDRE MEDVED: Counsel, can you repeat the question?

COL STREIT: If you look at paragraph 67.

AIRCDRE MEDVED: 67.

45

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 COL STREIT: You say there are 12 Airworthiness Boards, two remote
Aviation Safety Reviews, and two out-of-session Airworthiness reviews on
the MRH-90 enterprise. You then say – at paragraph 70, you set out
common themes across the Airworthiness Board reports. So I’m simply
5 asking you whether the common themes you’ve expressed – at
paragraph 70(a) through to (f) – you’ve drawn those common themes from
your consideration of the 12 Airworthiness Board reports and other
documents listed at para 67?

10 AIRCDRE MEDVED: That is correct. What I would state is that some of

those points are more prominent at different phases, from introduction of
Service right through to the last Board in 2021.

COL STREIT: Yes. Thank you. Sir, thank you for your time. That’s the
15 evidence-in-chief.

MS McMURDO: All right then. Well, you’d like a short break?

COL STREIT: Yes, please, Ms McMurdo. I note the witness has been
20 going for a little while, and the Board has been going for longer.

MS McMURDO: Yes.

COL STREIT: Or the Inquiry has been going for longer. So a short
25 comfort break of 10 minutes.

MS McMURDO: Okay. We’ll resume at 3.30 then. Thank you.

30 HEARING ADJOURNED

HEARING RESUMED

35
MS McMURDO: Just before we resumed, I think the Air Vice-Marshal
has a question to - - -

AVM HARLAND: It’s just a question relating to the cessation of MRH-90

40 operations following the accident on 28 July and the decision to, I guess,
formally, and permanently, cease operations. My question is just from a
DASA point of view, from an airworthiness and safety point of view, asking
whether you had any input to that decision?

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 AIRCDRE MEDVED: Yes, I did, per my statement. I was engaged and
were consulted on the briefing material supporting the decision to
Commander Avn Command over the weekend. And I supported that
decision.
5
AVM HARLAND: And that was in the immediate aftermath?

AIRCDRE MEDVED: That was on 27 and 28 July. Sorry – correction –

29 and 30 July.
10
AVM HARLAND: And following on from that, that decision to more
permanently cease operations and then dispose of the aircraft?

AIRCDRE MEDVED: I was not aware of the decision to – I was not

15 engaged on the decision to cease operations. And in terms of the disposal,
I was not engaged on the disposal strategy because the disposal strategy
does not have any bearing on Aviation safety. But DASA did provide
advice once they – when I say “they” – once a disposal strategy was
communicated, DASA did provide advice on what the minimum approvals
20 were required to execute that strategy.

AVM HARLAND: If I’m to take it from what you’ve said then, DASA, as
the Airworthiness Regulator for Defence, didn’t have an input into the
decision to permanently cease MRH-90 flying operations?
25
AIRCDRE MEDVED: We did not have a - - -

AVM HARLAND: After that initial decision had been made.

30 AIRCDRE MEDVED: Yes. I do want to correct. The decision was

socialised with me directly, so I was consulted. But that was for factual
correctness, not for providing any position per se on the decision.

MS McMURDO: So just to make sure I’ve understood it correctly then,

35 unexceptionally, after such a dreadful accident, you wanted to ground the
MRH until it was found out if there was involvement in – what the safety
implications were of the accident. So that was the initial grounding of the
MRH?

40 AIRCDRE MEDVED: That’s correct. That’s correct, Ms McMurdo.

MS McMURDO: Then as to the permanent and slightly earlier grounding

of the MRH, that’s because it was going to be decommissioned in any case
before too long?
45

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 AIRCDRE MEDVED: At the end of 2024.

MS McMURDO: Yes. You were informed about that. You were

contacted about it only in respect of checking some details, checking some,
5 facts but you weren’t involved in the decision-making.

AIRCDRE MEDVED: That is correct.

MS McMURDO: Thank you. Yes, COL Streit. Thank you.

10
COL STREIT: Thank you, Ms McMurdo. I can indicate there’s no
requirement for a private hearing. I understand there may be some
applications.

15 MS McMURDO: Applications to cross-examine?

MR O’MAHONEY: Yes, please, Ms McMurdo, on behalf of Airbus

Australia.

20 MS McMURDO: Thank you. I’m not sure if that means you’re the only
one or you’re just going to be coming forward first, but please - - -

MR O’MAHONEY: Thank you.

25
<CROSS-EXAMINATION BY MR O’MAHONEY

MR O’MAHONEY: Sir, my name is O’Mahoney. I appear for Airbus in

30 this Inquiry. I want to ask you firstly some questions about the role of
Airworthiness Boards generally. You’ve given some evidence about that.
Tell me if you agree with this: that the thrust of your evidence is that they
form an important role in relation to Aviation safety in Defence?

35 AIRCDRE MEDVED: That is correct, in giving independent assurance to

the Defence Aviation Authority.

MR O’MAHONEY: And I think you made it clear that that independent

assurance is aimed at complementing or supplementing the assurance
40 provided by DASA?

AIRCDRE MEDVED: That is correct. What I’d also flag is that a number
of years ago DASA did not fulfill its regulatory remit against its full scope
and was dependent upon Airworthiness Boards to complete that
45 independent assurance, in particular, for flight operations.

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 MR O’MAHONEY: And I think you touched on this at paragraph 65 of
your statement, but am I right in thinking that the Independent
Airworthiness Boards, to your mind, play a particularly important role
5 where DASA’s assurance provides what might be described as “only
limited confidence”?

AIRCDRE MEDVED: That is correct.

10 MR O’MAHONEY: In other words, if DASA doesn’t express confident

views in its findings as to Aviation safety, the Board then perhaps plays an
even more significant role than usual?

AIRCDRE MEDVED: No, I wouldn’t agree with that assertion. I would

15 state that where DASA may provide limited oversight. For example, if we
– or in instances where Defence may operate civil-registered aircraft, our
level of oversight is markedly less. So Airworthiness Boards may wish, in
some instances, where we conduct less assurance – it doesn’t mean we’re
less confident.
20
MR O’MAHONEY: I see. No, thank you.

AIRCDRE MEDVED: But we conduct less.

25 MR O’MAHONEY: Thank you for explaining that. And am I right in

thinking that as a general rule the Airworthiness Boards convene, more or
less, each year?

AIRCDRE MEDVED: I would say on average it’s probably closer to

30 18 months to two years but again, the scheduling is risk based. So some
platforms are more frequent, up to 12 months, whereas others – we do have
some platforms where the period is extended up to four years.

MR O’MAHONEY: And when you say “risk based” in giving that

35 answer, is that another way of saying they convene really on a needs basis?
If there’s an amplified level of risk, they might convene more often, but if
the opposite is the case, they might convene less often.

AIRCDRE MEDVED: Yes.

40
MR O’MAHONEY: And just focussing in on the Airworthiness Review
Board for the MRH, you’ve given detailed evidence in your statement about
that it’s not a memory test, but does it accord with your recollection that
that Board pretty much met once a year, every year, between 2007 and
45 2021?

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 AIRCDRE MEDVED: Well, you can do the maths, and where 16
independent reviews are conducted. So it is roughly once per annum.

5 MR O’MAHONEY: Quite. And there was at least a couple of years where

there were out-of-session meetings. There was two meetings per annum;
correct?

AIRCDRE MEDVED: There were two out-of-session reviews, yes.

10
MR O’MAHONEY: And I think in 2012 there was a deferral for a year;
correct?

AIRCDRE MEDVED: I would have to check my notes to confirm that.

15
MR O’MAHONEY: No. And it’s not a memory test, but I just wanted to
see if that jagged a memory with you. But I think this will certainly align
with your memory. After that position between 2007 and 2021, there was
to be a meeting of the Airworthiness Board in November 2022; correct?
20
AIRCDRE MEDVED: Correct.

MR O’MAHONEY: DASA provided a submission in relation to that

proposed Board meeting; correct?
25
AIRCDRE MEDVED: Correct.

MR O’MAHONEY: And you authored that submission?

30 AIRCDRE MEDVED: I signed and approved the submission but it was a

collective effort across DASA staff.

MR O’MAHONEY: And just explain briefly the difference between

signing and approving versus authorising?
35
AIRCDRE MEDVED: The difference is that I rely on my regulatory
experts across different scopes in the authority to pull the data together, and
then to compile the aggregated report. I review it. Based on my knowledge,
I may deep-dive or question some elements. And then, when I’m satisfied,
40 I sign it.

MR O’MAHONEY: And then the upshot of it is that you don’t sign it

unless you’re satisfied as to the accuracy of the contents; correct?

45 AIRCDRE MEDVED: Correct. Correct.

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 MR O’MAHONEY: Now, I’ll approach this with some sensitivity
because I don’t want to cause the Inquiry to go into closed session. But if I
could just invite you to turn up Annex D to your statement? You’ve got
5 that in front of you?

AIRCDRE MEDVED: Yes, I do.

MR O’MAHONEY: If you just go to what is internally page 12 of that

10 document and look at paragraph 34. Please don’t read it out. Have you
read that to yourself?

AIRCDRE MEDVED: I have.

15 MR O’MAHONEY: Is it fair to say that that is a fair summary of the

conclusion DASA arrived at in providing the submission to the
Airworthiness Board before the proposed November 2022 meeting?

AIRCDRE MEDVED: That is correct.

20
MR O’MAHONEY: Sir, you may or may not be able to answer this, but
was it the fact that the Board didn’t convene as scheduled, in November
2022, because of the positivity in that ultimate conclusion?

25 AIRCDRE MEDVED: No, I do not recall that was the reason.

MR O’MAHONEY: Well, in light of the answers you gave moments ago

about the Board convening on an “as needs” basis and doing so more often
if it was necessary, having regard to the risk, can we take it, at least at a
30 general level – you may not be able to agree with this – but is it your
understanding that the reason the Board didn’t convene as scheduled, in
November 2022, was because there was a degree of comfort about the risk
associated with this program?

35 AIRCDRE MEDVED: I would not characterise it as a degree of comfort

with the program, but there were other sensitive drivers that dictated the
delay to the Board.

MR O’MAHONEY: What were they?

40
AIRCDRE MEDVED: And the Command’s responses and industry
responses were all provided to support the Board, but I’m not willing to
disclose those sensitive drivers in the open forum here.

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 MR O’MAHONEY: And I certainly won’t invite you to. But can I ask
you this: do you engage pretty closely with the Board in the context of this
DASA submission process?

5 AIRCDRE MEDVED: Not the submission – not prior to the DASA

submission, but we do engage the Board members in advance of each
Board.

MR O’MAHONEY: Can the Inquiry take it that, based on your

10 experience, an Independent Airworthiness Board would not go ahead with
a decision to defer a meeting for a year if it thought there was amplified
levels of risk in relation to a particular program?

AIRCDRE MEDVED: I think it’s fair to say, if there was an immediate

15 safety issue or safety concern, that they would have. And if they thought
that risks were not adequately managed, they would have conducted a
Board.

MR O’MAHONEY: You’d agree, in those circumstances, it would be

20 irrational to defer an Independent Airworthiness Board meeting for
12 months?

AIRCDRE MEDVED: That is correct. My recollection is that when it was

deferred, it wasn’t deferred for that – it wasn’t originally deferred until
25 August. It was scheduled to be conducted earlier, but I’d have to go through
records to determine exact dates on when it was originally deferred to.

MR O’MAHONEY: Thank you. It’s not a memory test. If I could get

you to turn up, please, Annexure C attached to your statement. Tell me,
30 without saying anything about the detailed contents of this document, this
is a submission that you signed on behalf of DASA ahead of what was to
be the 9 August 2023 meeting of the Airworthiness Board. Correct?

AIRCDRE MEDVED: Correct.

35
MR O’MAHONEY: As it happened, you signed this four days before the
tragic accident that brings us here?

AIRCDRE MEDVED: Correct.

40
MR O’MAHONEY: If you turn to page 15 of this document, and just read
to yourself paragraph 43. You’ve read that quickly?

AIRCDRE MEDVED: I’m very familiar with it.

45

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 MR O’MAHONEY: I’m sure you are. Tell me, does that fairly capture
the upshot of DASA’s robust investigative work in advance of that
proposed Board meeting?

5 AIRCDRE MEDVED: It does.

MR O’MAHONEY: Does it align with your recollection that the last time
the Board met was in December ‘21?

10 AIRCDRE MEDVED: Yes, it does, because I participated in that.

MR O’MAHONEY: Does it also accord with your memory that there

were no ACARs issued at that last Board meeting, now some years ago.

15 AIRCDRE MEDVED: That is correct.

MR O’MAHONEY: If I could ask you to turn up paragraph 71 of your

statement, sir. This is a series of paragraphs directed towards the role of
DASA in the continuing operation of MRH-90. Do you see that?
20
AIRCDRE MEDVED: I do.

MR O’MAHONEY: Tell me if you agree with this summary of your

evidence in this regard, that at paras 71 and 72 you’re setting out there a
25 summary of the investigative work and regulatory role of DASA?

AIRCDRE MEDVED: I would say the regulatory role, not – and I don’t
want to confuse independent investigation. As a regulator, you do
investigations as well, but it’s separate to the DFSB investigatory function.
30
MR O’MAHONEY: Really, the point you’re trying to make here and
elsewhere in the statement, is I think that when it comes to DASA’s
regulatory work, it conducts robust assessments?

35 AIRCDRE MEDVED: That is my view.

MR O’MAHONEY: The upshot of those robust assessments, you would

say to the Inquiry, is robust conclusions and recommendations?

40 AIRCDRE MEDVED: I would say robust independent assurance

benchmarked against other comparable Military Aviation Authorities.

MR O’MAHONEY: Is it fair to say, looking at paragraph 73, that one

such conclusion, based on the robust work of DASA, is set out there in
45 relation to this MRH-90 capability; that the conclusion is that DASA has

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 been assured that the aircraft system has been designed, constructed, and
operated to approved standards and limitations by competent and authorised
personnel acting as members of an approved organisation? Is it fair to say
that is an accurate summary of DASA’s view?
5
AIRCDRE MEDVED: That is correct.

MR O’MAHONEY: Equally, where it goes on to say the response to

product failures, malfunctions and defects identified in Service has been
10 acceptable, that is again another accurate reflection of the ultimate
conclusion arrived at by DASA in relation to this program?

AIRCDRE MEDVED: That is correct.

15 MR O’MAHONEY: Turning just briefly to paragraphs 69 and 70 of your

statement, at paragraph 69 you refer to Annexure B. Again, I’m not going
to ask you to traverse the detail of that for the obvious sensitivity reason,
but am I right in thinking that you have crafted Annexure B based on your
own review of some source documents?
20
AIRCDRE MEDVED: That is tabling – that is a summary of all the source
documents, correct.

MR O’MAHONEY: But it’s your summary; correct?

25
AIRCDRE MEDVED: That is correct.

MR O’MAHONEY: In other words, you sat down with those source

documents and, to the best of your ability, tried to capture those in summary
30 form?

AIRCDRE MEDVED: When you say “tried to”, all of the items that are
flagged are explicitly identified in the reports.

35 MR O’MAHONEY: I certainly wasn’t being critical when I said “tried

to”.

AIRCDRE MEDVED: No, but there - - -

40 MR O’MAHONEY: But can I ask you this, though: what were the
documents you had regard to in putting together Annexure B?

AIRCDRE MEDVED: All the source reports.

45 MR O’MAHONEY: Are they all annexed to your statement?

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 AIRCDRE MEDVED: No, they’re not.

MR O’MAHONEY: Did you make a decision not to annex them?

5
AIRCDRE MEDVED: My understanding is that those documents have all
been provided to the IGADF Inquiry, so I did not see the value of providing
them again.

10 MR O’MAHONEY: Have you listed anywhere in your statement all of

the documents that you summarised in Annexure B?

AIRCDRE MEDVED: I believe so. I’ll just need to check. It does not
appear that they’ve been individually referenced, but like I said, all those
15 documents have been provided to the IGADF Inquiry.

MR O’MAHONEY: What are those documents?

AIRCDRE MEDVED: They are all of the Airworthiness Board reports

20 signed by the respective Airworthiness Board panel members that
conducted the Airworthiness Boards, Aviation Safety Reviews, and those
two other reviews that were conducted that you highlighted earlier.

MR O’MAHONEY: What about submissions to the various Boards that

25 have convened across the journey, did you have regard to those?

AIRCDRE MEDVED: No, I – given that some of the packages –

for example, that December ‘21, the total package in page number count
was in the order of 5000 pages. I did not go through individual components
30 that comprised the data packs in compiling Annex B.

MR O’MAHONEY: So is that another way of saying you didn’t have

regard to DASA’s submissions for the purposes of preparing Annexure B?

35 AIRCDRE MEDVED: No. For the purpose of providing Annexure B, the

intent there was to summarise the Airworthiness Board reporting findings.

MR O’MAHONEY: I realise that. But if you could answer my question.

Am I right in thinking that in putting together Annexure B, you didn’t have
40 regard to submissions made by DASA?

AIRCDRE MEDVED: I did not – for the purpose of Annex B, in the

context of why I provided it against the questions I was asked in the
submission, I did not view it was relevant to reconsider DASA contribution

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 to the data pack that underpinned the conduct of the Board and the
subsequent Board report findings.

MR O’MAHONEY: Can we take it from that answer as well that you

5 equally didn’t review the submissions made by Airbus at different stages?

AIRCDRE MEDVED: That’s correct.

MR O’MAHONEY: Again, I’m not being critical of you.

10
AIRCDRE MEDVED: Yes.

MR O’MAHONEY: I just want to understand what Annexure B is based

upon.
15
MS McMURDO: Would that be beyond as far as they were contained in
reports, or they were summarised in the reports?

AIRCDRE MEDVED: Ms McMurdo, the reason I only – I was referring

20 to the findings of the Independent Board of Review, the Airworthiness
Board.

MS McMURDO: Yes.

25 AIRCDRE MEDVED: And it’s their words and how they weighed up
different contributions.

MS McMURDO: Yes.

30 AIRCDRE MEDVED: And it was their conclusions that I was referencing.

MS McMURDO: Yes, I see. But what I’m saying is, it may be, in that
doing that, they’ve made reference to submissions by DASA or Airbus in
that report. And as far as that goes, did you have a look at that?
35
AIRCDRE MEDVED: The Board reports don’t include references.

MS McMURDO: They don’t.

40 AIRCDRE MEDVED: All they acknowledge is that there were – is the

data pack, which is an aggregation of all the inputs.

MS McMURDO: Thank you.

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 MR O’MAHONEY: Thank you. And in the interests of saving a little
time, I think you’ve already given evidence to this effect, but I just want to
be clear, that where you say at paragraph 70, “common themes that are
present in most reports”, you’ll accept, I think, that when one looks at the
5 various subparagraphs (a) through (f), at least some of them only appear at
specific points in time between 2007 and 2021?

AIRCDRE MEDVED: That is correct. And that’s what I reflected in my

earlier evidence, that the prominence of some of those themes does vary
10 over time.

MR O’MAHONEY: Quite. You’d agree as well, some of them are

historic in nature, in the sense that they emerged at an early point in the
program but, with the passage of time, fell away.
15
AIRCDRE MEDVED: I think that would be – that could only be stated
really for 70(a).

MR O’MAHONEY: Thank you. Going to the one immediately below

20 that, which deals with CAMM2, that’s a software program; correct?

AIRCDRE MEDVED: That is correct.

MR O’MAHONEY: It stands for Computer-Aided Maintenance

25 Management system; correct?

AIRCDRE MEDVED: Correct.

MR O’MAHONEY: It’s directed towards digitising logistics systems;

30 correct?

AIRCDRE MEDVED: It is an electronic maintenance management

system. Could you please repeat the question?

35 MR O’MAHONEY: It’s a software system aimed at assisting with

digitising management – logistics management.

AIRCDRE MEDVED: I wouldn’t – and I’m sorry to be painful - - -

40 MR O’MAHONEY: You’re not, but I’ll move on, in the interests of time.

AIRCDRE MEDVED: I just don’t – yes.

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 MR O’MAHONEY: Tell me this – well, you know it’s a software system
that Defence uses to assist with logistics. There’s no doubt about that, is
there?

5 AIRCDRE MEDVED: I would be more precise and use the term

“maintenance”, “required maintenance to be conducted on the aircraft”.

MR O’MAHONEY: It was introduced in or about 2005?

10 AIRCDRE MEDVED: That is correct.

MR O’MAHONEY: Replaced what was called CAMM1?

AIRCDRE MEDVED: Simply CAMM, correct.

15
MR O’MAHONEY: Or CAMM; I won’t cavil with that. And CAMM or
CAMM1, that was bedevilled with problems – correct – by the time it was
phased out?

20 AIRCDRE MEDVED: It was a legacy system developed in the late 70s,

early 80s.

MR O’MAHONEY: It’s been the case, hasn’t it, that across the journey
of CAMM2, it, itself, has been plagued with problems; correct?
25
AIRCDRE MEDVED: I’m not in a position to answer that.

MR O’MAHONEY: That’s not something you’re aware of?

30 AIRCDRE MEDVED: There have been – I’m aware that there have been
some challenges, but there has been a continued process for updates. And
from Australia’s experience, and even with some other international
operators, the CAMM2, as an airworthiness records management system,
and from a configuration and control perspective, provides us much greater
35 confidence than some other systems used by large, respected foreign
militaries.

MR O’MAHONEY: Have you received feedback, internally or

externally, sir, to the effect that CAMM2 is both unsuitable and outdated?
40
AIRCDRE MEDVED: Could you repeat that, please?

MR O’MAHONEY: Have you received feedback, either internally or

externally, to the effect that CAMM2, this software program, is unsuitable
45 and outdated?

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 AIRCDRE MEDVED: To the first part, unsuitable? No. Outdated? No.

MR O’MAHONEY: Never?
5
AIRCDRE MEDVED: There have been updates to address some
vulnerabilities, I agree. But I have not heard that word “outdated”, or – I’m
not suggesting that it may not have been used, but not to my awareness.

10 MR O’MAHONEY: Do you have any views yourself on the

appropriateness of Defence using a management software system that is
now approaching 20 years old?

AIRCDRE MEDVED: No, I don’t; on the basis that I know it’s continually
15 updated.

MR O’MAHONEY: Do you know whether or not it’s earmarked for

replacement?

20 AIRCDRE MEDVED: Yes, it is.

MR O’MAHONEY: Is one of the reasons it’s earmarked for replacement

because stakeholders within Defence have formed the view that it’s no
longer fit for purpose?
25
AIRCDRE MEDVED: I’m not aware of that view.

MR O’MAHONEY: You gave an answer earlier to learned Counsel

Assisting in relation to the language of “rate of effort” that you use in
30 paragraph 70. And thank you for clarifying that; it was a question I had for
you. Am I right in thinking that that is a shorthand way of capturing what
is sometimes referred to as “availability rates”?

AIRCDRE MEDVED: No, that’s simply a measure of number of flying

35 hours that were achieved. It does have a linkage to availability, but it’s not
directly linked.

MR O’MAHONEY: I want to ask you just a few questions about

availability rates to see if I can jog your memory. Are you aware that in
40 2022 and 2023, 6 Aviation, in terms of the management of maintenance of
its fleet, its MRH-90 fleet, was relying on industry?

AIRCDRE MEDVED: I’m not aware of specific details, but I am aware

that industry was providing maintenance support services to Aviation
45 Command.

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 MR O’MAHONEY: Specifically, when I say “industry”, you’d know
Airbus Australia?

5 AIRCDRE MEDVED: I do know that.

MR O’MAHONEY: Airbus has been heading up the maintenance efforts

at Aviation 6 in 2022/2023; correct?

10 AIRCDRE MEDVED: I would have to check my notes to confirm that.

MR O’MAHONEY: If I said to you that availability rates at 6 Aviation

for those couple of years have reached around 76 per cent, does that align
with your recollection, broadly?
15
AIRCDRE MEDVED: I don’t have – in my role, I would – I don’t have
any direct responsibilities, nor would it make sense to provide that
information to me.

20 MR O’MAHONEY: And can I ask you this? In relation to 5 Aviation, is

it your understanding that for those two years Defence was responsible for
the maintenance of the fleet?

AIRCDRE MEDVED: I would have to confirm the notes – with the notes.
25
MR O’MAHONEY: Are you aware that, broadly speaking, for those
two years, availability rates at 6 Aviation were around 34 per cent?

AIRCDRE MEDVED: Like I said earlier, that detail, from a performance

30 perspective, is normally – it does not serve – or is not of importance and
would not necessarily be raised – or that comparison would not necessarily
be raised with me in my role.

MR O’MAHONEY: Has anyone drawn to your attention an offer that’s

35 been made by Airbus to assist 5 Aviation with its serviceability or
availability rates?

AIRCDRE MEDVED: I don’t recall.

40 MR O’MAHONEY: Thank you, sir. I don’t have any more questions.

MS McMURDO: Yes, were there any other applications to cross-

examine? Yes.

45

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 <CROSS-EXAMINATION BY LCDR GRACIE

LCDR GRACIE: I may be three minutes. Maybe I can bank the other five.
5
Sir, my name is LCDR Malcolm Gracie. I represent the interests of
CAPT Danniel Lyon. Can I just ask you to look at paragraph 73 of your
statement, please? I just want to tease out the words in the first sentence
where you say:
10
For the MRH-90 capability, DASA has been assured that the
aircraft system has been designed, constructed and operated to
approved standards and limitations by competent and authorised
personnel acting as members of an approved organisation.
15
Can I ask you what the source of that assurance is through these approved
organisations, starting perhaps – I won’t say at the bottom – but starting
perhaps with – would it be with AATES, who might conduct some testing,
or would it be something prior to that?
20
AIRCDRE MEDVED: If I talk about designed – I’ll focus on designed and
operated.

LCDR GRACIE: Yes.

25
AIRCDRE MEDVED: And I would also insert, although it’s not stated
explicitly, maintained.

LCDR GRACIE: Yes.

30
AIRCDRE MEDVED: So ongoing design work is conducted by Airbus as
an approved organisation. Maintenance is conducted by approved
organisations, both Aviation Command and Airbus, and other component
Maintenance Organisations in Australia and overseas. And the operator at
35 this point in time, in 2023, was Aviation Command. They were approved
to operate it, and as part of that activity individuals and crew need to be
authorised and approved.

LCDR GRACIE: But when we’re talking about approved organisations,

40 there is a series of layers, can I say, within Avn Command where there is a
testing process, there is an evaluation process. I really want to see where
AATES Aviation – Army Aviation Testing and Evaluation Section – fit into
this structure. Do they come under the umbrella of Avn Command?

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 AIRCDRE MEDVED: That is my understanding, but you would need to
confirm that with Aviation Command.

LCDR GRACIE: Yes, and then under Aviation Command – I don’t think
5 it’s the case now, but it was the case that it came under the Commandant of
the Aviation Training Centre. Is that how - - -

AIRCDRE MEDVED: I don’t recall.

10 LCDR GRACIE: Where does AATES, as a Licensed Testing

Organisation, fit in with the structure that you, on behalf of DASA, rely
upon to assure that the aircraft system is airworthy?

AIRCDRE MEDVED: What I would say is we don’t – when we provide

15 an organisational approval, it is an enterprise organisational approval that
covers all operations. For example, with Aviation Command, it covers all
organisational aspects within that Command for flight operations. So
AATES operating under that Military Air Operator would still need to
comply with currency, proficiency and skilling requirements that are
20 applicable to the Military Air Operator for the aircraft that they are
operating.

LCDR GRACIE: Do I understand that where you said that DASA has
been assured of these various things by these approved organisations, that
25 DASA relies upon those organisations for its information?

AIRCDRE MEDVED: It’s through the conduct of our – the initial

establishment of those organisations, and our ongoing oversight and
enforcement, which is detailed in – the references in the DASA submissions
30 to Airworthiness Boards details the flight operations oversight activities
that were conducted.

LCDR GRACIE: And that’s really what I just want to get to. I had
understood that DASA had that oversight role, but in response to a question
35 from Counsel Assisting where you said DASA approved the V5.10 upgrade
of the symbology, you said that there was an internal justification for it.

AIRCDRE MEDVED: So to clarify, what I said earlier is DASA provides

authorisations in the form of permits, approvals and licences for
40 organisations, products and people. So there are organisational approvals,
which I’ve discussed. Where I said “approval of that modification”, that is
a product approval associated with the aircraft-type design, and in reference
to internal – so we will have a document that articulates our formal approval
of that modification. Underpinning that, internally we have our own

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 authorisation processes for staff within DASA to document our rationale,
and what is being done to support the DASA approval.

LCDR GRACIE: Thank you. So there is an internal DASA report

5 approving the symbology upgrade?

AIRCDRE MEDVED: There is.

LCDR GRACIE: There was one other question. Do you know if that went
10 to an internal – sorry, I withdraw that. Do you know if that went through,
or was reviewed by, an Airworthiness Board, or a Remote Safety Review
Board?

AIRCDRE MEDVED: No, it was not, because this is a regulatory

15 function, and within the remit of DASA. Airworthiness Boards do not have
a role within the regulatory system.

LCDR GRACIE: But it was a major airworthiness change.

20 AIRCDRE MEDVED: It was a major change to type design, correct.

LCDR GRACIE: But do you say that comes outside of the airworthiness
oversight of the Airworthiness Boards?

25 AIRCDRE MEDVED: An Airworthiness Board, despite the name, looks

at all aspects that impact Aviation safety beyond the strict definition of
“airworthiness”, which is a reflection of an aircraft being safe to fly. They
meet periodically and look at all facets. As part of their review, they also
look at what DASA does from an assurance perspective.
30
LCDR GRACIE: As far as you’re aware, just to confirm, there was no
Airworthiness Review Board, remote or otherwise, that reviewed this major
change to the aircraft type with the upgrade of the symbology to
(indistinct) - - -
35
AIRCDRE MEDVED: No, because we conduct multiple major changes to
type design. It’s not uncommon for multiple changes – major changes to
type design occurring on individual aircraft every year.

40 LCDR GRACIE: Thank you. Thank you, sir.

LCDR TYSON: Ma’am, I’ll just be very brief.

MS McMURDO: Yes.
45

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 <CROSS-EXAMINATION BY LCDR TYSON

5 LCDR TYSON: My name’s LCDR Matthew Tyson. I appear for

CPL Naggs, one of the aircrew, sir. So I just want to ask you about
paragraph 70(f) in your statement. You say this:

The MRH-90 Airworthiness Board summary details a long history

10 of an Aviation system under stress.

And then you go down to (f), and it says:

There was an aggregated risk to Aviation safety, inclusive of

15 airworthiness, that was challenging to characterise and quantify.

Can you please explain what you mean by that, sir?

AIRCDRE MEDVED: Sure. If I talk about aggregated risk to Aviation

20 safety, what we’re talking about is the risk of a – you know, a significant or
tragic event during operations. What contributes to that? It can be through
multiple causes. It could be something to do with the maintenance. It could
be a latent defect in design. It could be something from production. It could
be from the way it was operated. There are thousands of – I won’t even say
25 “thousands”.

The reason Aviation is so heavily regulated is because of the complexity of

the systems, and the number of individual contributions that can lead to a
catastrophic loss of aircraft. Given that there were some risks that were
30 being managed across multiple areas that can impact Aviation safety, it is
difficult to quantify individual contributions of those risks, and aggregate it
into – aggregate it in a manner, let alone quantify it, in a measurable way.

LCDR TYSON: And that view that you have in paragraph 70, that opinion
35 was applicable as at early 2023?

AIRCDRE MEDVED: What I’d like to flag is that is not my opinion. That
is the opinion of a succession of Airworthiness Board panel members who
signed the reports.
40
LCDR TYSON: So that takes into account the number and accumulation
of those Airworthiness reports in relation to the MRH-90 as at early 2023?
That’s the summary - - -

45 AIRCDRE MEDVED: It’s a common theme across – yes.

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 LCDR TYSON: And you’re certainly aware, sir, aren’t you, that, I think
on 22 March 2023, an MRH-90 ditched in Jervis Bay in quite benign flying
conditions? You’re aware of that, aren’t you, sir?
5
AIRCDRE MEDVED: I’m fully aware of that.

LCDR TYSON: And that’s a circumstance that you would’ve taken into
account in reaching the summary that you set out at paragraph 70?
10
AIRCDRE MEDVED: Paragraph 70, again, is not a reflection of – it’s not
my view; it’s from the Board reports. And the last Board report predates
the March ditching in Jervis Bay.

15 LCDR TYSON: Yes. It predates that; is that right?

AIRCDRE MEDVED: Correct.

LCDR TYSON: But part of the aspect was that some of the risks to
20 Aviation safety that was involved in the MRH-90 platform, they actually
couldn’t be characterised and quantified as at early 2023? Or the scope of
them, the full scope of them, couldn’t be quantified?

AIRCDRE MEDVED: It is very difficult to quantify individual – to

25 numerically quantify individual contributions. That is no different to civil
aviation, which is why there are decades of best practice and establishment
of controls that are proven to be effective in managing – or operating aircraft
safely and managing risk, and inclusive of that is elevated levels of risk.

30 LCDR TYSON: Thank you, sir. Thank you, ma’am.

MS McMURDO: Thank you. Any other applications to cross-examine?

AVM HARLAND: A follow-on question, actually, ma’am.

35
With that, you’re saying that paragraph 70(f) was effectively a summary of
the Board reports and the outcomes. Wouldn’t that seem contrary to the
idea of deferring or cancelling the 2022 Airworthiness Board?

40 AIRCDRE MEDVED: Contrary, if there was not confidence that the risks
were being managed and there were controls in place.

AVM HARLAND: So?

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 AIRCDRE MEDVED: So you might not – it might be challenging to
characterise and quantify the risk level. And the way risk is characterised
is quite broad under Aviation Risk Management or Defence Health Risk
Management approaches. But there was confidence in the controls that
5 have been put in place to manage the risks.

AVM HARLAND: Great. Okay, thank you.

MS McMURDO: Any re-examination?

10
COL STREIT: No, Ms McMurdo. The witness can be excused.

MS McMURDO: Yes. Thank you very much, Air Commodore. You’re

excused.
15

<WITNESS WITHDREW

20 MS McMURDO: And we’ll adjourn the Inquiry until Monday morning at

10 o’clock. Thank you.

PUBLIC INQUIRY ADJOURNED UNTIL

25 MONDAY, 12 AUGUST 2024 AT 1000

.MRH-90 Inquiry 09/08/24 2292 J J MEDVED XXN

© C’wlth of Australia